050358 10.26.2020 EM
REQUEST TO REMOVE MEMBERS FROM THE HOUSEHOLD
You can request changes online at our website: www.hacosantacruz.org Call the Housing
Authority to get your personalized Registration Code. Click on Online Portals in the Main
Menu. Select Resident Portal. After you register, select Report An Income or Family
Composition Change.
PLEASE COMPLETE THE FOLLOWING FORM TO REMOVE ONE OR MORE MEMBERS FROM YOUR HOUSEHOLD.
YOU ARE REQUIRED TO SUBMIT THIS FORM TO THE HOUSING AUTHORITY WITHIN 14 CALENDAR DAYS OF
THE DATE OF THE MOVE OUT.
Full Legal Name of Head of Household: __________________________________________ Tenant ID: ___________________
Phone Number: _______________________
I. MEMBERS TO BE REMOVED
List all persons who you would like to remove from your household.
(age 18 or older)
as appears on Social Security Card
Social Security
Number
Relation to
Head of
Household
Date of Move
Out
Address where the removed
household member is moving (or
has moved)
(55 Main Street, City State Zip Code)
/ /
/ /
/ /
B. Children (under 18 yrs)
as appears on Social Security Card
(Sample: John Matthew Smith)
Social Security
Number
Relation to
Head of
Household
Date of Move
Out
Address where the removed
household member is moving (or
has moved)
(55 Main Street, City State Zip Code)
/ /
/ /
/ /
By signing this form, I certify that the above information is true, correct, and complete and will be relied upon for purposes
of determining my level of assistance in a federal housing program. Any misstatement or false statement may result in denial
/ loss of assistance. In addition, I understand that any misrepresentation in my statements may be considered to be fraud and
I may be required to repay all assistance overpaid on behalf of my family.
WARNING – TITLE 18 SECTION 1001 OF THE UNITED STATES CODE STATES THAT ANY PERSON
WOULD BE GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR
FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES.
Print Head of Household Name Signature Date
