550114 JP 090109
VACATE DATE CERTIFICATION FORM
Please complete this form, and return the form to the Housing Authority as soon as you move out of your
unit. Your transfer can not be completed until this form has been submitted to the Housing Authority.
Name of Head of Household:
__________________________________________
Contact Telephone Number:
Address of the Unit you are vacating:
___________________________________
______________________________________________________________________
______________________________________________________________________
I certify that my household vacated the above unit on ________________________.
(Date)
I certify that I have provided my landlord with proper notification of my move out date in compliance with
the terms and conditions of my lease.
By signing this form, I certify that the information provided above is true, correct, and complete. I understand that if I
do not give proper notice to my landlord, that I may be terminated from participation in the Section 8 Housing Choice
Voucher Program. Also, I understand that this form may be provided to my landlord upon request.
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.
Tenant Signature (required)
________________________________________________________________________
Signature Date
Tenant Forwarding address:
________________________________________________________________________
________________________________________________________________________
New phone or message number:
________________________________________________________________________
________________________________________________________________________
For any questions on completing this form or to verbally confirm your vacate date
please call HA at (831) 454-9455, Ext. 233.
