Request To Add Family Member

Head of Household

First Name (Head of Household)

Last Name (Head of Household)

SSN

Phone

Address [Street Name and Number]:

City:

State:

Zip:

Person You Wish To Add

Please complete the following to add a family member. Completion of this form does not guarantee that the request will be granted. You will receive a written response regarding the approval or denial of this request.

Name

Relationship To Head of Household

SSN

Date of Birth

What Income Does This Person Have?

Address [Street Name and Number]:

City:

State:

Zip:

Why Do You Want to Add This Person to Your Household?

Documents Needed

Birth Certificate:

Social Security Card:

Picture ID (18 and over):

Information Release Form (HUD 9886) Declaration 214 Form (Download Form):

Members 18 and Over Must Sign the Release Form and Declaration 214 Form (Download Form):

A background check will be conducted on anyone 18 and over to verify that they have no criminal history before request will be considered.

I declare under penalty of perjury, that the above information is true and complete.

Signature of Head of Household:

WARNING: Title 18, Section 1001 of the United States Code, states that a person who knowingly makes false or fraudulent statements to any department or agency of the United States is guilty of a felony.