Fillable 8933 Interchange Dr. REQUEST TO REMOVE HOUSEHOLD MEMBER

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8933 Interchange Dr. REQUEST TO REMOVE HOUSEHOLD MEMBER

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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 REMOVE HOUSEHOLD MEMBER
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
Fill in the following information for each member you are requesting to remove.
Birth Date
Age
Sex
Does this person have
dependents?
Yes
No
If yes, who?
New
Address
In order for your request to be processed, you must attach TWO of the following documents with your request. If all
required documents are not submitted, your request will not be processed.
Removing Minor
Removing Adult
Updated Lease from your current landlord
AND
Updated Lease from your current landlord
AND
Updated residence on school records
Utility Bill for new address
Death certificate/ Obituary
Death certificate/Obituary
Medical Stay (Rehab/Therapy) Records
Current lease from their new landlord
Jail Records (Incarcerated)
Jail Records (Incarcerated)
Current lease from their new landlord
Medical Stay (Rehab/Therapy) Records
----------------------------------------------------DO NOT WRITE BELOW THIS LINE----------------------------------------------------
COFC
Date Reviewed:
Staff Initials:
Method of Verification:
Effective Date:
Vou Size:
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8933 Interchange Dr. REQUEST TO REMOVE HOUSEHOLD MEMBER

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Completed 15 December 2021

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