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Housing Allowance Designation Form

Please return the completed form to: Human Resources, Sampey Hall 4118. Changes submitted after the fifteenth of the month will not be processed until the following month.

Personal Information:

Ordained Print Name (Last, First, MI) Licensed

Employee ID number

Position

Housing Allowance: A designated housing allowance may not exceed the fair rental value of your home plus the cost of utilities or the amount you actually spend for housing, whichever is less.

$

Monthly Designation

(please round to nearest whole dollar)

Effective Date for change

Signature

Date

2825 Lexington Road Louisville, KY 40280 (502)897-4721

Information

1 pages

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