Change in Household Composition Form Form for document upload and resident updates Form Instructions*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. I understand My Name* Head of Household*Me/SelfSomeone elseFull Name of Head of Household Reason head of household is not completing this form Unit Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is mailing address different than unit address?* No, its the same Yes I have a different mailing address Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number* Phone Type* Cell Home Other Email Are you in the Family Self-Sufficiency Program?*-NoYesDo you live in Franklin Heights?*-NoYesWho is your HRHA caseworker?*-JonKimberlyI don't knowAre you REMOVING any household member?*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. -NoYesAre you ADDING any household member?*-NoYesNote: This form can handle ONE addition. For more household additions please fill out a separate form. Removing a household memberMember Name Member AgeEffective Date of Move-Out MM slash DD slash YYYY Reason for Move-Out? Are you removing another household member?NoYesNote: A removed member may not be eligible to return to the householdMember Name Member AgeReason for Move-Out? Effective Date of Move-Out MM slash DD slash YYYY Documentation to submit to your caseworker*Please select which documents you will be submitting to your case worker to help finalize removal. Select all that apply. Lease, utility bill, or letter from new landlord School records showing new address for minors Custody paperwork Written certification of adult moving out How will you submit required documents?*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. I will email them to my caseworker I will have agency/organization/landlord email to my caseworker I will submit them with this online form (see below) I will deliver them to the main office Adding a household memberAre you adding due to birth, adoption, or court-awarded custody?-NoYesAdding: Birth, adoption, or court-awarded custodyIf multiple additions, you will need to fill out a separate form for eachPlease select reason for addition*-BirthAdoptionCourt-awarded custodyEffective date of birth, adoption, or court-awarded custody* MM slash DD slash YYYY Relationship to head of household* Name of household addition* First Middle Last Date of birth* MM slash DD slash YYYY Gender* Male Female Place of Birth (City, State)* Citizenship*-US Citizen/NationalEligible Non-CitizenIneligible Non-CitizenRace*Racial and ethnic information is for statistical purposes only. While Black/African-American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Other Hispanic or Latino?* Yes No Are you receiving any income on behalf of this household member such as adoption income, social security, SSI, or child support?* Yes No Income Type* Income Amount ($)* Income Frequency (How often do you receive this income?)* REQUIRED DOCUMENTS*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. Social Security Card or letter from SSA confirming member's SSN (required - in office) Birth Certificate (required - in office) Citizenship Declaration Form (required - in office) Adoption Papers or court-awarded custody, if applicable Household AdditionAllowable AdditionsAllowable 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. I have read the policy on allowable additions Anticipated effective date for addition* MM slash DD slash YYYY Relationship to head of household* Reason for addition. Please explain.*New household member's name* First Last Date of Birth* MM slash DD slash YYYY Gender* Male Female Place of Birth (City, State)* Citizenship* Race*Racial and ethnic information is for statistical purposes only. While Black/African-American American Indian/Alaska Native Asian Native Hawaiian/Other Pacific Islander Other Hispanic or Latino?* Yes No Is this person disabled?* Yes No Is this person a student?* No Yes, part time Yes, full time Educational Program* Does this new household member receive any income?*Examples: wages, child support, TANF, unemployment, pension, social security, SSI, alimony, Self-employed business, regular gifts or contributions, educational grants, etc Yes No Income Details*Please list out all income sources, amounts, and frequency (how often the income comes in)Does this new household member have any assets?*Examples: checking account, savings account, retirement account, 401(k), stocks, bonds, etc Yes No Asset Details*Please list out all assets and their current amounts, income generated (like interest), and other relevant details. Document Verification/Submission*Your case worker will need a variety of documents before approving or rejecting your request to add a new household member. I understand that documents must be provided to my caseworker and my request verified before I can add a member to my household REQUIRED DOCUMENTS*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. Social Security Card or letter from SSA confirming member's SSN (required) Birth Certificate (required) Citizenship Declaration Form (required) Photo I.D. of new member (required) Documentation of any income (if applicable) Documentation of any assets (if applicable) Final CheckPlease check your answers above to make sure information is accurate.Questions or comments?File Upload - No Sensitive Personal Identifying Information**This includes your social security number, bank account number, passport info, and other sensitive content that could be stolen and used against you. I will not upload any documents that contain sensitive personal identifying information Upload File(s)* 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 Select files Accepted file types: jpg, jpeg, png, pdf, doc, docx, Max. file size: 512 MB. True and Correct*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. I CERTIFY THAT ALL INFORMATION PROVIDED IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE.
