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.