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Family Member Move Out

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Notification of Family Member Move – Out

 

Instructions: Please complete this form and submit it to your PHA representative immediately in the event that any family member(s) move out of your housing unit.

 

Date: _______________________________

 

Head of Household ______________________________________________________________

 

Address ___________________________________________________________ Apt No. _____

 

Telephone # _________________________________

 

Please answer the following questions:

 

Name of family member who moved  ________________________________________________

 

Date that the family member moved _________________________________________________

 

What is the new address of this person? ______________________________________________

 

                                                                 ______________________________________________

 

                                                                  _____________________________________________

 

What is the new telephone number of this person? ______________________________________

 

What income did this person have? __________________________________________________                                                                                            

 

 

 

 

Signature of Head of Household___________________________________________________

 

 

 

 

 

 

 

WARNING: Section 1001 of Title 18 of the U.S. Code make it a criminal offense to make willful False statement or

Misrepresentation to any Department of Agency of the United States as to any matter within its jurisdiction.

 

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