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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


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



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


1 pages

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