Process To Request A Change In Household Composition Form Page 2
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2CHANGE IN HOUSEHOLD COMPOSITION REQUEST
Head of Household:____________________________________________________Last 4 of SSN:___________________
Current Address:____________________________________City___________________State__________Zip__________
Email Address:______________________________________ Telephone Number________________________________
**Your request will not be processed without the below listed, required verification **
MANDATORY ADDITIONS TO THE HOUSEHOLD (Please check all that apply):
Birth
Adoption
Court-Award Custody
Foster-Care
1)
Name:_____________________________________________ Relationship to Head of Household______________________________
Date of Birth:_______________________________ Social Security Number: ___________________________________________________
2)
Name:_____________________________________________ Relationship to Head of Household______________________________
Date of Birth:_______________________________ Social Security Number: ___________________________________________________
**Please attach a copy of the following, for each person being added to the household: Birth certification, Social Security Card, Declaration of 214 Status, and if
applicable, court order custody and/or adoption paperwork and foster care documentation.
DISCRETIONARY ADDITIONS TO THE HOUSEHOLD (Please check all that apply):
(CMHA MUST APPROVE THE REQUEST 30 DAYS PRIOR TO MOVE-IN)
Marriage
Adding a previously removed household member
Other _____________________________________________________
1)
Name:_____________________________________________ Relationship to Head of Household______________________________
Date of Birth:_______________________________ Social Security Number: ___________________________________________________
2)
Name:_____________________________________________ Relationship to Head of Household______________________________
Date of Birth:_______________________________ Social Security Number: ___________________________________________________
**Prior to approving the addition of the listed household member, CMHA will schedule an appointment where the Head of Household and person listed above
member must attend and provide required documentation. The scheduled appointment is mandatory prior to the additional household member(s) move-in date.
REMOVING A MEMBER FROM THE HOUSEHOLD:
Permanent (will be absent from the household for more than 90 days)
Temporary (will be absent from the household for less than 90 days i.e. foster care placement, entering medical facility,
incarcerated etc.)
Name:____________________________________________________ Move Out Date______________________________
New Address:_________________________________________________________________________________________
Name:____________________________________________________ Move Out Date______________________________
New Address:_________________________________________________________________________________________
By signing below, I have released information to CMHA with regards to my household composition. I am also certifying that the information
provided with regards to my household composition is true and accurate to the best of my knowledge. I understand that any false statements
contained herein may result in the termination of my housing assistance through the Housing Choice Voucher Program and/or retroactive
rent charges.
Household member completing this form:___________________________________________________________________
Signature ________________________________________________________ Date: _______________________________
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