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Change in Household Form

You are here: Home1 / Change in Household Form

Change in Household Composition Form

Form for document upload and resident updates
  • This form is to update HRHA about adding or removing a member of your household. In addition to this form you will need to send documents to your caseworker or drop them off at the main office. Submission of this form does not mean the immediate approval of a household addition or removal. Please answer all questions fully and accurately. You cannot save this form. Complete the form in full at one time.
  • Note: A removed member may not be eligible to return to the household This form can handle TWO removals. For additional removal please fill out an additional, separate form.
  • Note: This form can handle ONE addition. For more household additions please fill out a separate form.
  • Removing a household member

  • MM slash DD slash YYYY
  • Note: A removed member may not be eligible to return to the household
  • MM slash DD slash YYYY
  • Please select which documents you will be submitting to your case worker to help finalize removal. Select all that apply.
  • Due to the coronavirus, digital submission is encouraged. If documents contain sensitive personal information (like social security number, passport information, bank account number, and more) then you MUST bring them to the main office.
  • Adding a household member

  • Adding: Birth, adoption, or court-awarded custody

    If multiple additions, you will need to fill out a separate form for each
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Racial and ethnic information is for statistical purposes only.
  • Please select the documents you will drop off at the HRHA Main office (286 Kelley St). We will mail back to you when we have recorded what we need. You can email your caseworker if you have questions about required documentation. You may NOT upload these documents with this form.
  • Household Addition

  • Allowable additions include approved live-in aides; foster children & adults; additions by marriage, domestic partnership or civil union; adult children age 18-21 who are full-time students; and parent(s) if disabled and/or age 62+ needing disability-related care. Additions for any other reasons are an exception to our policy and require a written explanation of the reason for the requested addition. Landlord approval of new members is required. Upon receipt of all required items, HRHA conducts a criminal background check before adding adults (persons age 18+). The head of household and approved adults must complete a briefing on program rules and sign required paperwork. SUBMISSION OF THIS REQUEST IS NOT AUTHORIZATION. YOU MAY NOT ADD PERSONS TO YOUR HOUSEHOLD UNTIL YOU RECEIVE WRITTEN APPROVAL FROM HRHA.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Racial and ethnic information is for statistical purposes only.
  • Examples: wages, child support, TANF, unemployment, pension, social security, SSI, alimony, Self-employed business, regular gifts or contributions, educational grants, etc
  • Please list out all income sources, amounts, and frequency (how often the income comes in)
  • Examples: checking account, savings account, retirement account, 401(k), stocks, bonds, etc
  • Please list out all assets and their current amounts, income generated (like interest), and other relevant details.
  • Your case worker will need a variety of documents before approving or rejecting your request to add a new household member.
  • Please select all of the documents you will drop off at the HRHA Main office (286 Kelley St). We will mail back to you when we have recorded what we need. You can email your caseworker if you have questions about required documentation. You may NOT upload these documents with this form. All documents are required.
  • Final Check

    Please check your answers above to make sure information is accurate.
  • This includes your social security number, bank account number, passport info, and other sensitive content that could be stolen and used against you.
  • * You may NOT upload files that contain ANY sensitive personal identifying information. If documents contain this information you MUST drop them off at the main office. This includes: - Social Security number - Personal bank account numbers - Passport related information - Credit or Debit Card information - Drivers License of State I.D.
    Drop files here or
    Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 512 MB.
    • I CERTIFY THAT ALL INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. Title 18, Section 1001 of U.S. Code states that a person is guilty of a felony for knowingly and willingly making a false or fraudulent statement to any department or agency of the United States Government.
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    P.O. Box 1071
    Harrisonburg, VA 22803

    Phone: 540-434-7386
    Fax: 540-432-1113

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    • Apply For Housing
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