Click here for the PA 901V.
Section I must always be completed.
The CAO must fill in the information at the top-right corner of the section.
The PHA office should fill in blocks 1 -6 as follows:
1. Enter the name and address of the PHA vendor.
2. Enter the date the interview with the tenant took place.
3. Enter the name of the CAO/District Office.
4. Enter the tenant’s DHS case record number, if known.
5. Enter the tenant’s Housing Authority account number.
6. Enter the tenant’s name, address, phone number and social security number. Use the same information that was entered on the original form PA 900V.
The PHA office should fill in blocks 7 thru 11 only if the information has changed since the original form PA 900V was filled out.
7. Enter the tenant’s new name, address, phone number or Social Security Number.
8. Enter the number of persons now living in the housing unit.
9. Enter the new current monthly rent.
10. Enter your own name, title and telephone number.
11. Enter a reason why the changes are needed.
If a tenant’s rent payment is being stopped, the PHA office or the CAO should fill in this section as follows:
12. Enter the PHA’s vendor ID number.
13. Check the right box for the reason, or give another reason the rent payment is being stopped.
The CAO should complete this section as follows:
14. Enter the individual's monthly and semi-monthly grant amounts before the rent is taken out.
15. Check the right box to tell whether the rent payment to the PHA is to continue or not.
If it is to continue at the same amount, check the box. Otherwise, enter the new amount and the effective date.
If rent payments are to be stopped, enter the effective date for them to stop.
16. If the vendor payment is changed or stopped, enter a reason.
17. Sign, enter your phone number and today’s date.
Revised October 18, 2024, replacing March 16, 2012