Request to Add / Remove Household Members to Application

Housing and Community Development (HCD)

Request to Add / Remove Household Member to Application
Head of Household Social Security Number #:
Date

MonthDayYear
Date
Head of Household Name:

First NameLast Name
Entity #:
Present Bedroom Size:
Head of Household has requested permission to add the following individuals to their application:

Rows	Name	Age	Sex	Relationship
Person 1

Head of Household has requested to remove the following individuals from their application:

Rows	Name	Age	Sex	Relationship
Person 1

Explain circumstances why this action is necessary:
Do you have a report and/or recommendation from Community Services? Give details:
Signature of Head:

Clear
Date

MonthDayYear
Date
Note: Pre-approval of PHCD is required prior to adding/removing a household member to the application or dwelling lease; once you have signed the dwelling lease only those household members listed may reside in the unit unless written authorization is granted by PHCD.
This material is available in an accessible format upon request.
Should be Empty:

Housing and Community Development (HCD)