Fillable 8933 Interchange Dr. REQUEST TO ADD MINOR 17

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8933 Interchange Dr. REQUEST TO ADD MINOR 17

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8933 Interchange Dr.
Houston, Texas 77054
Tel: 713-578-2100
Fax: 713-669-4594
www.hchatexas.org
hcha@hchatexas.org
Title 18 Section 1001 of the US Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent
statements to any department of the U.S. government.
REQUEST TO ADD MINOR – 17 YEARS & UNDER
Section 1: To be filled out by Head of household
Head of household
Phone Number
Email Address
Last four of social
security number:
I declare, under penalty of perjury, that the information provided is true and complete. I acknowledge that HCHA will
require landlord consent before changes can be finalized.
Head of Household Signature
Date
Complete below and attach the following: birth certificate, social security card, proof of income, and sign attached
forms (Declaration of Citizenship)
Print Full Name
(Include Jr, Sr, etc.)
Birth Date
Age
Sex
Relationship to
head of household
Social Security
Number
Disabled:
Yes
No
Ethnicity:
Hispanic
Non-Hispanic
Race:
White
Black
American Indian
Pacific Islander
Asian
Is minor
adopted?
Yes No
Foster child?
Yes No
Do you have legal
custody of child?
(Attach proof)
Yes
No
Income?
Yes No
If yes,
describe
source:
High school or
college student?
Yes No
If yes, where:
----------------------------------------------DO NOT WRITE BELOW THIS LINE----------------------------------------------------
COFC
Date Reviewed:
Staff Initials:
Method of Verification:
Effective Date:
Vou Size:
Each person who will benefit under the Section 8 Rental Assistance Program must either be a citizen or national of
the United States, or be a noncitizen who has eligible immigration status that qualifies them for rental assistance as
determined by the U.S. Department of Housing and Urban Development and the U.S. Immigration and
Naturalization Service.
I am a
citizen or
national of
the U.S.
I am a
noncitizen
with eligible
immigration
status.
First Name Last Name
Warning -
Title 18 US Code Section 1001 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. If this form contains false or incomplete
information, you may be required to repay all overpaid rental assistance you received; fined up to $10,000, imprisoned for up
to 5 years; and/or prohibited from receiving future assistance.
Signature of Adult Listed to the left,
or Signature of Guardian for Minors.
NOTE: Family members who have checked a box indicating that they are a noncitizen with
eligible immigration status must complete Part 2 of this form.
Part 1: Applies to All Family Members
Age
DECLARATION OF CITIZENSHIP
PLEASE COMPLETE THIS FORM AND RETURN TO:
September 26, 2014
One box on this form must be checked for each family member indicating status as a citizen or a national of
the United States, or a noncitizen with eligible immigration status. Family members residing in the unit to
be assisted that do not claim to be a citizen or national of the United States, or do not claim to be a
noncitizen with eligible immigration status should not check any box.
All adults must sign where indicated. For each child who is not 18 years of age, the form must be signed by an
adult member of the family residing in the dwelling unit who is responsible for the child. Use blank lines to add
family members who are not listed.
Tenant ID
or
X
X
or
X
or
X
or
X
or
X
or
X
or
X
or
X
or
DZ 9/26/2014 Page 1© HAPPY Software, Inc.
/150299172338/
Evidence supplied with this form may be released by the Housing Agency, without responsibility for its further use or
transmission, to the Immigration and Naturalization Service for purposes of verification of the immigration status of the
individual or to the U.S. Department of Housing and Urban Development, as required. The U.S. Department of Housing and
Urban Development is not responsible for the further use or transmission of the evidence or other information.
All family members who have claimed eligible immigration status on Part 1 of this form must provide this office with an
original of one of the following documents:
(1) Form I-551, Alien Registration Receipt Card
(2) Form I-94, Arrival-Departure Record with appropriate annotations or documents
(3) Form I-688, Temporary Resident Card
(4) Form I-688B, Employment Authorization Card
(5) A receipt issued by the INS indicating that an application for issuance of a replacement document in one of the above-
listed categories has been made and the applicant’s entitlement to the document has been verified.
Please call at to arrange for delivery and copying of original documents.
Do not mail original documents to this office.
If documents are not presented and verified, your family’s rental assistance may be reduced, denied, or terminated as provided
in regulations promulgated by the U.S. Department of Housing and Urban Development, pending available appeals processes.
Each family member required to complete Part 2 of this form must sign below granting consent to verify eligible
immigration status. For each child who is not 18 years of age, the form must be signed by an adult member of the family
residing in the dwelling unit who is responsible for the child.
Consent to Verify Eligible Immigration Status
Office Use Only
INS VERIF. #
As head of household I certify, under penalty of perjury, that all members of my household are listed on Part 1 of this form
and that members of my household that have not checked either box on Part 1 of this form do not claim to be citizens or
nationals of the United States, or noncitizens with eligible immigration status.
Head of Household Certification
Signature Date
First Name
Part 2: Applies to Noncitizen Family Members Only
Last Name
X
Signature of Adult Listed to the left,
or Signature of Guardian for Minors.
X
X
X
X
X
X
X
X
Age
DZ 9/26/2014 Page 2© HAPPY Software, Inc.
/150299172338/
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8933 Interchange Dr. REQUEST TO ADD MINOR 17

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Completed 24 January 2022

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