Fillable FORM 12. REQUEST TO ADD A HOUSEHOLD MEMBER: (City of New York)

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FORM 12. REQUEST TO ADD A HOUSEHOLD MEMBER: (City of New York)

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Division of Tenant Resources
HEAD OF HOUSEHOLD NAME
SOCIAL SECURITY
NUMBER
(last 4
digits)
FORM 12. REQUEST TO ADD A HOUSEHOLD MEMBER
Complete this form to declare any additions to your household by birth,
adoption, marriage, or domestic partnership or if you would like to request that
any other individuals be added to your household. All proposed additions to
household age 18 and over will be screened for criminal background and sex
offender registration. Failure to get approval from HPD for all proposed
additions other than by birth, adoption, marriage or domestic partnership
may be cause for the termination of Rental Subsidy assistance.
TO BE COMPLETED AND SIGNED BY THE HEAD OF HOUSEHOLD AND
PROPOSED MEMBER
Have you
completed this
form?
Yes
Applicable
_______________________ _____________________ _______________________ _____ ____ ________
LAST NAME FIRST NAME RELATIONSHIP TO SOCIAL SECURITY NUMBER
HEAD OF HOUSEHOLD
____/____/____ Sex: Male Female Are you disabled? Yes No Are you a student? Yes No
BIRTH DATE
Are you employed? Yes No If YES, please complete “Verification of Wages” (Form 4). If NO,
complete “Declaration of All Income” (Form 3).
Declaration of Citizenship Status Citizen Non-citizen with Eligible Immigration Status Non-citizen
who chooses not to declare Eligible Immigration Status
If your status is “Citizen” you must provide documentation if “Non-citizen with Eligible Immigration
Status,” you must include one of the following documents: 1) Alien Registration Card (Form I-551), 2)
Arrival Departure Record (I-94), 3) Temporary Resident Card (I688), or Employment Authorization Card (I-
688B). If “non-citizen who chooses not to declare” household subsidy will be based on the number of
eligible citizens and legal residents in the household.
I certify that the above information is accurate and understand that providing false statements to a
government agency is punishable under federal law and may result in loss of subsidy.
_______________________________________________
______________________________
SIGNATURE OF PROPOSED HOUSEHOLD MEMBER DATE
OR GUARDIAN (IF UNDER 18)
_______________________________________________
______________________________
SIGNATURE OF HEAD OF HOUSEHOLD DATE
Requiredforallproposedhouseholdmembers18yearsofageandolder:
AphotoID,SocialSecuritycardandbirthcertificate
Proofofprioraddress
Asigned“AuthorizationfortheReleaseofInformation”(Form1)
ASigned“DeclarationofEmploymentStatusForm”(Form2)
Documentationofanyincomereceivedbytheproposedhouseholdmember
Requiredforallproposedhouseholdmembersunder18yearsofage:
Legalcustodydocumentsoraletterfromasocialserviceproviderstatingthechildpermanently
resideswiththeHeadofHousehold
AcopyofSocialSecuritycard
Acopyofbirthcertificate
“VerificationofAbsentParent(s)”(Form9)(ifapplicable)
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FORM 12. REQUEST TO ADD A HOUSEHOLD MEMBER: (City of New York)

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Completed 28 January 2021

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