Skip to content

Plymouth Housing Commission

Marital Separation Status Affidavit

Marital Separation Status Affidavit

Name(Required)
Address(Required)
Spouse's Name(Required)
Our housing commission provides affordable housing under Section 42 of the Internal Revenue Code. Households applying for occupancy are required to disclose their marital status and future intentions for purposes of determining income eligibility.

Who should complete this form: If you are age 18 or older or an emancipated minor and you are currently separated from your spouse, this form must be completed.

The US Government requires the following:
- All questions must be answered YES, NO or,
- If a question does not apply, put N/A.
- If uncertain, use best available information
- Use of “White out” and pencil is prohibited.
- If information must be changed, strike through & initial change.
- Signature and date of person completing this form is required.
Choose and complete the appropriate numbered statement below:(Required)
MM slash DD slash YYYY
Choose and complete the following appropriate statement:(Required)

Fill in the blanks from your previous selection

Amount of Money
Frequency

For the following reason(s)

Certify the Message Below

Consent(Required)

Contact Information

1160 Sheridan, Plymouth, MI, 48170 | Phone: 734-455-3670 | Fax: 734-455-2429 | Email: hcvprogram@plymouthhousing.net

Website Design by Shumaker Technology Group