Attach evidence of all income details for all new and existing household members

Changes to your household

Complete this form to tell us that you have had someone move into or out of your property, or that you or someone that lives with you has had a change to their income.

	

Postcode	
Phone:
Email:	

Tenant/s name:
Tenancy Reference No.
Property Address

Preferred contact details:

What do we need?

Tell us about the change in your household by completing the tables below.
Provide copies of income evidence for all people living at your home. These can include:
A Centrelink or Department of Veteran’s Affairs Income and Assets Statement.
An Employers Declaration or 4 weeks of payslips for each person receiving wages, a salary or casual income.
A Tax Assessment Notice for the previous financial year for each self-employed person, including a Centrelink PAYG statement if also in receipt of a Centrelink income. Profit and loss statements are not accepted.
Evidence of any other income received (for example, last quarterly bank statements, statements from financial institutions showing the total amounts of income earned from shares, bonds or managed investments).
All legal tenants in your household need to sign the declaration on the second page.
Post or deliver the form and household income information back to your local Housing Service Centre or email the information to HHSSDCPT@chde.qld.gov.au within 28 days of the change.

New Household Member
Please list the details of all new people in the table below:
Given Name	Family Name	Date of Birth	Relationship to Tenant/s
(partner, son, friend etc.)	Date moved in	Indigenous Origin
(Aboriginal, Torres Strait Islander, South Sea Islander, N/A)	

						

						

Household Member Vacating

Please list the details of all people who have left your home in the table below:
Given Name	Family Name/s	Relationship to Tenant/s
(partner, son, friend etc.)	Date moved out	

				

Note: if the vacating household member is a tenant (e.g. has signed the State Tenancy Agreement) they must complete a Notice of Intention to Leave (RTA Form 13). This form is available online at www.rta.qld.gov.au or from your local Housing Service Centre or any Australia Post Office.

Attach evidence of all income details for all existing household members

Change of Income
Please list the details of all people who have had a change of income in the table below:
Given Name	Family Name/s	Date of change	

			

Attach evidence of all income details for all existing household members

Any other information
Please include any other information that you need us to know:

	

DECLARATION
All tenants (legal tenants listed on the State Tenancy Agreement) must sign below.
To the best of my knowledge, the information provided on and in conjunction with this form is true and correct. I/We understand that it is an offence liable to a penalty under the Housing Act 2003 and a breach of my State Tenancy Agreement to knowingly provide false or misleading information to the Department of Housing.

Name:	Name:	Name:	
Signature:	Signature:	Signature:	

Date:	/	/	Date:	/	/	Date:	/	/