Applicant Change Form printable pdf download

___ Housing Choice Voucher

Applicant No: __________

___ Public Housing

Applicant No: __________

___ Hope VI

Applicant No: __________

___ Dakota Park

Applicant No: __________

APPLICANT CHANGE FORM

Dear Applicant:

The following information is needed ONLY if there has been a change in your address, family composition, income,

current housing or living arrangements.

PLEASE PRINT and complete entire form.

Client Name: _________________________________________ SSN:___________________

Current Address: _____________________________________

_____________________________________

Phone Number(s):

Home No: _________________ Work No: _________________ Other/Message No: _________________

Check the box that applies to your Application Change:

My mailing address has changed. My new mailing address is:

_______________________________________________

My family composition has changed. My new family composition is as follows:

Name

Relationship

Sex

Age

SSN

DOB

Please Note: If you are removing a family member from your application, please indicate the reason why:

____________________________________________________________________________________________________.

My housing situation has changed. My new housing information is as follows:

________________________________________________________________________________________________.

Are you now living in Public Housing or HUD subsidized Housing?

Yes

If yes, please tell us where? ________________________________________________________________________.

My family income has changed. My new family income is as follows:

Please update your income:

Employment, Unemployment Comp, Social Security, SSI, TANF, Direct Contributions, etc.

New Employer: _______________________________ Phone No: ____________ Hire Date: ________

Address: _____________________________________

_____________________________________ Rate of pay: $____________(Hourly)

Hours per week: ____________ I get paid:

Weekly

Bi-Weekly

Monthly

Former Employer: ____________________________________ Phone No: ______________________

Address: ____________________________________________ Last date of work: _________________

____________________________________________

Reason for leaving employment: _________________________________________________________________.

Other changes in family income (explain):__________________________________________________________.

WARNING:

Section 1001 of Title XVII of the United States Code makes it a criminal offense to make willful gales statements or misrepresentations to any

department or agency of the United States as to any matter within its jurisdiction. I certify that the above information is correct and I understand

that any misrepresentation will be grounds for denial or termination with the Section 8 Housing Voucher Program or Public Housing Program.

_____________________________________________

______________________________________

Client’s Signature

Date

(PLEASE SIGN ATTACHED AUTHORIZATION RELEASE OF INFORMATION)

Lakeland Housing Authority

Created: 10/09/2006

430 Hartsell Avenue

Revised: 06/11/2008

Lakeland, FL 33805

(863) 687-2911

Applicant Change Form

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