Page 1078

West Virginia Income Maintenance Manual Chapter 10

West Virginia Income Maintenance Manual Page 87 Chapter 10 The Case Maintenance Process

2. If the address where you live has changed, please write your NEW address below.

Street Address:

Apt. #:

City, State: Zip: Phone: Directions to your home:

If the address where you get your mail is different, please write your new mailing address below. Post Office Box #: or Street Address: Apt. #: City, State: Zip: 3. Please enter the amount paid each month for the items below or zero (0) if you no longer pay this expense. If you now pay a shelter or utility expense that is not listed, please write it in the section listed as other. If any agency or individual not living in your home now pays all or part of these expenses, please list the amount that they pay and whether it is paid to you or directly to the company that bills you. PLEASE CIRCLE YOUR PRIMARY SOURCE OF HEATING OR COOLING.

Type of Expense Amount Owed Each Month Paid By (Self, HUD, etc.) Rent/Mortgage Payment, Lot Rent, Property Tax, Homeowner’s Ins., Etc. $ Electric $ Gas $ Propane $ Fuel Oil $ Sewer/Water $ Other $

4. Has anyone moved into or out of your household? Yes No If yes, complete the chart below.

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Page 1078

Official source

West Virginia Income Maintenance Manual Chapter 10

West Virginia Income Maintenance Manual Page 87 Chapter 10 The Case Maintenance Process

2. If the address where you live has changed, please write your NEW address below.

Street Address:

Apt. #:

City, State: Zip: Phone: Directions to your home:

If the address where you get your mail is different, please write your new mailing address below. Post Office Box #: or Street Address: Apt. #: City, State: Zip: 3. Please enter the amount paid each month for the items below or zero (0) if you no longer pay this expense. If you now pay a shelter or utility expense that is not listed, please write it in the section listed as other. If any agency or individual not living in your home now pays all or part of these expenses, please list the amount that they pay and whether it is paid to you or directly to the company that bills you. PLEASE CIRCLE YOUR PRIMARY SOURCE OF HEATING OR COOLING.

Type of Expense Amount Owed Each Month Paid By (Self, HUD, etc.) Rent/Mortgage Payment, Lot Rent, Property Tax, Homeowner’s Ins., Etc. $ Electric $ Gas $ Propane $ Fuel Oil $ Sewer/Water $ Other $

4. Has anyone moved into or out of your household? Yes No If yes, complete the chart below.