Declaration Of Change In Household Composition And Income Form

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DECLARATION OF CHANGE IN HOUSEHOLD COMPOSITION AND INCOME
The purpose of this form is to report any changes that have occurred to a household since an application was
submitted for Section 8 subsidy. Complete this form to request to add or remove people from the household
composition; or to report changes of income or assets for members of the household. All proposed additions
to the household of a person age 18 and over will be screened for criminal background and lifetime sex
offender registration.
TO BE COMPLETED AND SIGNED BY THE HEAD OF HOUSEHOLD AND NEW HOUSEHOLD MEMBER:
Are you requesting to add a person to the household?
Yes
No
If yes, complete Part A. The new household member must also sign the second page of this form.
Are you requesting to remove a person from the household?
Yes
No
If yes, complete Part B.
Are you reporting a change in income or assets for an existing member of the household?
Yes
No
If yes, complete Part C.
____________________________________________________________________________________________
PART A:
REQUEST TO ADD A PERSON TO THE HOUSEHOLD
____________________
_____________________
_______________________
_____ - ____ -______
LAST NAME
FIRST NAME
RELATIONSHIP TO
SOCIAL SECURITY NUMBER
(OF PERSON TO BE ADDED)
HEAD OF HOUSEHOLD
Sex:
Male
Female Are you disabled?
Yes
No
Are you a student?
Yes
No
____/____/____
If yes and do not receive SSI, read and have completed
If yes and member is 18 or older, have Form 8.
BIRTH DATE
Form 3: Verification of Disability.
Verification of Student Status completed.
Declaration of Citizenship Status
Citizen
Non-citizen with Eligible Immigration Status
Non-citizen
I CHOOSE NOT TO DECLARE MY IMMIGRATION STATUS
If a household member selects not to declare his or her immigration status, subsidy
will be based on the number of eligible citizens and legal residents.
If your status is “Citizen,” provide documentation such as a birth certificate, a passport, or
naturalization papers. If your status is “non-citizen with eligible immigration status,” you must
provide one of the following documents:
1) Alien Registration Card (Form I-551), 2) Arrival/Departure Record (I-94), 3)
Temporary Resident Card (I-688), Employment Authorization Card (I-688B).
Are you employed?
Yes
No
If Yes, please complete the sections below and Form 4: Verification of Wages. If No, also
complete the section below and submit documentation for all other sources of income received. Please review the “What is Income?” form to
understand the different types of income.
INCOME SOURCE
AMOUNT
EMPLOYER NAME AND PHONE NUMBER OR TYPE OF INCOME
(IF OTHER
Employment
Other ___
$___________
THAN EMPLOYMENT):
PER ___________
_______________________
(Frequency, i.e., per
week, month, day)
INCOME SOURCE
AMOUNT
EMPLOYER NAME AND PHONE NUMBER OR TYPE OF INCOME
(IF OTHER
Employment
Other ___
$___________ PER ____
THAN EMPLOYMENT):
_______________________
Do you have any assets?
Yes
No
If Yes, please read the form “What is an Asset?” complete the section below,
and include documentation from each institution for each account.
TYPE OF ASSET AND INSTITUTION:
ACCOUNT #
VALUE
________________________________________
____________________
$_____________
TYPE OF ASSET AND INSTITUTION:
ACCOUNT #
VALUE
________________________________________
____________________
$_____________
TYPE OF ASSET AND INSTITUTION:
ACCOUNT #
VALUE
________________________________________
____________________
$_____________
Additional documents to be submitted for new household member:
Required for all proposed household members 18 years of age and older:
A photo ID, proof of social security number, documentation of age, and proof of citizenship or
legal resident status
A signed Form1: Authorization for the Release of Information
Required for all proposed household members under 18 years of age:
Legal guardianship documents or a letter from social service provider stating the child
permanently resides with the head of household if neither biological parent is in the
household
Proof of social security number, documentation of age, and proof of citizenship or legal
resident status
Form 9: Verification of Absent Parent(s) form (if applicable)

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