Dear Client:
We are committed to processing your Interim Change in Family Composition request in a timely manner. However,
all of the required documentation to support the change must be submitted with the request.
Change request forms must be complete, signed and legible. We cannot accept requests that are incomplete.
Interim Change Request Packets can be submitted in person by mail. If mailing, send only copies, and do not include
original documents.
Due to processing constraints, we can only provide a status on interim changes that have been submitted at least
30 days prior. Status requests can be submitted via email to interim@housingforhouston.com, and we will provide
a status via email within 3 business days (not including weekends or holidays). Don’t forget to check your spam
mailbox.
Before you allow anyone to move into your unit other than by birth, legal adoption, or court awarded custody, they
must be approved by the Houston Housing Authority and your landlord. Failure to receive advance approval from
HHA could result in termination of assistance. If you are approved for a Change in Family composition, an approval
letter will be mailed to you and to the landlord. If your request has been denied, a denial letter will be mailed to
you and your landlord within 30 days.
A Change in Family Composition must be completed for each member being added or removed from the household.
HHA Interim Change Request Forms and Required Documents
1.
2.
3.
Change in Family Composition packet returned with all pages.
Request for Change in Family Composition Form must be signed and returned with the required documents.
Houston Housing Authority Required Forms
o HUD Authorization to Release of Information – 9886 (Must be signed by head of household and anyone in household
18 and older)
o Criminal Background Check (Must be signed by head of household and new family member being added 18 and older)
rd
o 3 Party Change in Family Verification Form (Proof of Income verification)
o Contribution and Gifts Letter
o Declaration Form
o Declaration of U.S. Citizenship or Non-Citizens with Eligible Immigration on Status
o Household Assets Self Certification Form
o Authorization for Release of Information (Must be signed by head of household and anyone in household 18 and older)
o Valid Texas photo-identification (Driver’s license or state ID)
o Birth Certificate
o Social Security Card
o School Verification Form (If Applicable. Must be filled out by the school with the students schedule included)
o Child Care Expenses Verification Form (If Applicable. Must be filled out by the child care provider)
Client must attach:
1. All Supporting Documentation
2.
3.
Request for Change in Family Composition Packet and Form
Houston Housing Authority Required Forms
Thank you,
HHA staff
Request for Change in Family Composition
Name of Head of Household ________________________________
Date _________________________________
Client ID #________________________________________ Social Security# _________________________________
Phone
____________________________
E-mail Address ____________________________________________
REMOVE from household: (Please provide full name and new address of person being removed)
REASON:
NAME: First and Last
NEW ADDRESS:
Please Print
ADD to household: (Please provide full name of person being added and complete all fields)
GENDER
REASON:
NAME: First and Last
Male
Female
Relationship to Head of Household
Date of Birth: Month/Day/ Year
Social Security#
Does this person have ANY source of
income?
Yes
No
Does this person have ANY dependents?
Yes
No
Please attach Supporting documents of proof. If all documents are not provided the request will not be processed.
Adding
18 years
or older:
Removing over 18 years:
Adding
18 years
or older:
•Change
Change of
of Family Composition
ChangeofofFamily
FamilyComposition
Composition
Form • Proof
ProofofofIncome
Income
CompositionForm
Form
• Change
Form
•Declaration
Declaration Form
Form
BirthCertificate
Certificate
Social
Security
Card
• Birth
• Social
Security
Card
•Death
DeathCertificate
Certificate / Obituary
Statepicture
pictureIDID(Must
(Mustbebe
valid)
CriminalBackground
Background
Form
Obituary
• State
valid)
• Criminal
Form
USDeclaration
DeclarationofofCitizenship
Citizenship
Form • Disposal
DisposalofofAssets
Assets
form
1.Copy of updated State ID or utility bill for family member
• US
Form
form
• HUD
Release
of of
Information
form
HUDAuthorization
Authorizationofof
Release
Information
form
removed showing their new address
• Letter
from
Owner/Manager
approving
request
Letterorornew
newlease
lease
from
Owner/Manager
approving
request
AND
Addingunder
under18
18 years
years of Age:
Adding
Age:
Lease or letter of HCVP participant from your Owner/Manager
• Change
Form
Certificate
or or
Birth
facts
ChangeofofFamily
FamilyComposition
Composition
Form •Birth
Birth
Certificate
Birth
facts
showing removal from household
• Social
• US
Form
SocialSecurity
SecurityCard
Card
USDeclaration
DeclarationofofCitizenship
Citizenship
Form
OR
• Court
letter
or or
Power
of Attorney
NOTNOT
Acceptable)
CourtAwarded
Awarded(Notarized
(Notarized
letter
Power
of Attorney
Acceptable)
2.Lease or letter from new Owner/Manager of family member
removed or statement from the person they are living with.
AND
Lease or letter of HCVP participant from your Owner/Manager
Showing removal from household .
Signature of Head of Household
Date
Removing Under 18 years of Age with Income
Change of
ofFamily
FamilyComposition
CompositionForm
Form
• Change
Written
letter
&
Proof
of
Address
(Must
provide
both)
• Written letter & Proof of Address (Must
provide
both)
Proof of
ofBeneficiary
Beneficiarychange
change(Child
(Child
support,
TANF)
• Proof
support,
SSI,SSI,
TANF)
• Death
DeathCertificate
Certificate/ /Obituary
Obituary
Removing Under 18 years of Age with no income
• Change of Family Composition Form
• Death Certificate / Obituary
Housing Choice Voucher Program
DECLARATIONS
(Please Print)
Client’s Name: _____________________
Social Security #: _______________________
I would like to declare the following:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________
Your Signature
_____________________________
Your address
_____________________________
Your phone #
_____________________________
Email
_________________________________
Date
CHANGE IN FAMILY COMPOSITION --3RD PARTY VERIFICATION
CONTACT INFORMATION
This form must be completed
Client Name:
Client #:
Employment (If applicable) Previous or Current
Corporate Company Name: ______________________________________________________________
Corporate Company Address: ____________________________________________________________
Phone number#: __________________________________ Fax#_______________________________
Address of actual work location: __________________________________________________________
Contributions (If applicable)
Contributors Name: ____________________________________________________________________
Contributors Address: __________________________________________________________________
Phone#: _____________________________________ Fax#____________________________________
School Verification (If applicable - 18 and older)
Name of School: _______________________________________________________________________
School address: _______________________________________________________________________
Phone#: _____________________________________Fax#_____________________________________
Child Care Provider (If applicable)
Name of Child Care Provider: _____________________________________________________________
Child Care Providers address: _____________________________________________________________
Phone#: ______________________________________Fax#____________________________________
Child Support (all filed child support orders, regardless of whether payment is received and proof of
payment)
Cause# _______________________________________________________________________________
CIN#_________________________________________________________________________________
Unemployment Benefits (If applicable)
Did you apply for unemployment benefits?
Yes (Attach status letter)
No (Must apply and provide proof)
Start Date: _________________________________
End Date: __________________________________
Weekly Benefit Amount: ______________________
Housing Choice Voucher Program
SCHOOL VERIFICATION
Due back by __ /__ /____
Date:
To
Client Name:
__ / __ /_____
Client #:
Student Name:
Student SS #:
The household member named above has applied for, or is recertifying eligibility for, housing assistance under a program of the U.S.
Department of Housing and Urban Development (HUD). HUD requires us to verify all information that is used in determining the
person’s eligibility or level of benefits.
Please make sure to include this completed form with your request for change along with a copy of the student class schedule.
I, _____________________ _________, consent to allow The Houston Housing Authority to request and obtain the income
information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s
assisted housing programs.
ATTENDANCE OFFICE OR ADMISSIONS OFFICE, PLEASE COMPLETE THE FOLLOWING:
This student is attending:
_____
Full-time
_____
Part-time
If attending College, University or Trade School:
Number of hours per semester ________
Signed: ___________________________________
Position: ___________________________________
Phone: ___________________________________
Fax:
___________________________________
Date:
___________________________________
Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly
and willingly making false or fraudulent statements to any department of the United States Government.
HHA APPLICANT/TENANT CERTIFICATION FOR CHILDCARE
EXPENSES
Client Name:
Client #:
I/We hereby certify that the following represent true and accurate statements regarding our household
circumstances related to childcare:

Child/children cared for are under 13 years of age.
Reason for care (check one)

Such care enables the following family member to work:
Occupation:
Employer, address & phone number:
Hours worked:

per
week,
month
Such care enables a family member to attend vocational or academic courses:
Member's name:
Course:
Institution name, address & phone #:
Hours at school:
Childcare costs are not paid to anyone living in our household; they are paid to:
Name:
Address & Phone # :

I/We do not receive reimbursement for childcare costs from any agency or individual outside the
household.

I/We recognize that the above statements are subject to third-party verification.
Signature
HHA CHILDCARE VERIFICATION
(Individual/Babysitter provides Care)
Dear Sir/Madam:
has applied for or is a participant in the Housing Choice Voucher
program.
Please fill in the blanks below and return this letter to us as soon as possible. All information is
confidential and is only used to help determine the participant’s housing subsidy.
Name(s) and age(s) of child(ren) cared for:
1.
4.
2.
5.
3.
6.
Name of Child Care Provider:
Address:
Phone #
Contact Person:
Childcare is provided on the following days for the hours indicated:
Monday:
hours
Tuesday:
hours
Wednesday:
hours
Thursday:
hours
Friday:
hours
Saturday:
hours
Sunday: hours
Total hours per week:
Total hours per month:
Cost of Care: $
, per week month.
$ received for care from family named above: $
,  week month.
$ received for care from others (if any): $
,  week  month.
Name of individual, program, or other third-party source providing childcare funds for this family:
Address:
Estimated cost of care to the family for the upcoming 12 months:
Signature
Date
TENANT/APPLICANT RELEASE
I,
Signature
, hereby authorize the release of the requested information.
Date
Authorization for the Release of Information/
Privacy Act Notice
U.S. Department of Housing
and Urban Development
Office of Public and Indian Housing
to the U.S. Department of Housing and Urban Development(HUD)
OMB CONTROL NUMBER: 2501-0014
and the Housing Agency/Authority (HA)
PHA requesting release of information; (Cross out space if none)
(Full address, name of contact person, and date)
IHA Requesting Release of information of information:(Cross out space if none)
(full address, name of contact person, and date)
Houston Housing Authority
2640 Fountain View Suite 100
Houston, TX 77057
Authority: Section 904 of the Stewart B. McKinney Homeless
Assistance Amendments Act of 1988, as amended by Section 903
of the Housing and Community Development Act of 1992 and
Section 3003 of the Omnibus Budget Reconciliation Act of 1993.
This law is found at 42 U.S.C. 3544.
This law requires that you sign a consent form authorizing: (1)
HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2)
HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for
keeping that information; (3) HUD to request certain tax return
information from the U.S. Social Security Administration and the
U.S. Internal Revenue Service. The law also requires independent
verification of income information. Therefore, HUD or the HA
may request information from financial institutions to verify your
eligibility and level of benefits.
Purpose: In signing this consent form, you are authorizing HUD
and the above-named HA to request income information from the
sources listed on the form. HUD and the HA need this information
to verify your household’s income, in order to ensure that you are
eligible for assisted housing benefits and that these benefits are set
at the correct level. HUD and the HA may participate in computer
matching programs with these sources in order to verify your
eligibility and level of benefits.
Uses of Information to be Obtained: HUD is required to protect
the income information it obtains in accordance with the Privacy
Act of 1974, 5 U.S.C. 552a. HUD may disclose information
(other than tax return information) for certain routine uses, such as
to other government agencies for law enforcement purposes, to
Federal agencies for employment suitability purposes and to HAs
for the purpose of determining housing assistance. The HA is also
required to protect the income information it obtains in accordance
with any applicable State privacy law. HUD and HA employees
may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the
consent form. Private owners may not request or receive
information authorized by this form.
Who Must Sign the Consent Form: Each member of your
household who is 18 years of age or older must sign the consent
form. Additional signatures must be obtained from new adult
members joining the household or whenever members of the
household become 18 years of age.
Persons who apply for or receive assistance under the following
programs are required to sign this consent form:
PHA-owned rental public housing
Turnkey III Homeownership Opportunities
Mutual Help Homeownership Opportunity
Section 23 and 19(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation
Failure to Sign Consent Form: Your failure to sign the consent
form may result in the denial of eligibility or termination of
assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA’s grievance procedures and
Section 8 informal hearing procedures.
Sources of Information To Be Obtained
State Wage Information Collection Agencies. (This consent is
limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have
received assisted housing benefits.)
U.S. Social Security Administration (HUD only) (This consent is
limited to the wage and self employment information and payments of retirement income as referenced at Section 61
03(l)(7)(A) of the Internal Revenue Code.)
U.S. Internal Revenue Service (HUD only) (This consent is
limited to unearned income [i.e., interest and dividends].)
Information may also be obtained directly from: (a) current and
former employers concerning salary and wages and (b) financial
institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these
sources will be used to verify information that I provide in
determining eligibility for assisted housing programs and the
level of benefits. Therefore, this consent form only authorizes
release directly from employers and financial institutions of
information regarding any period(s) within the last 5 years
when I have received assisted housing benefits.
Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the
purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that receive
income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently
verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be
given an opportunity to contest those determinations.
This consent form expires 15 months after signed.
Signatures:
Head of Household
Date
Social Security Number (if any) of Head of Household
Other Family Member over age 18
Date
Spouse
Date
Other Family Member over age 18
Date
Other Family Member over age 18
Date
Other Family Member over age 18
Date
Other Family Member over age 18
Date
Other Family Member over age 18
Date
Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by
the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing
Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to
submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other info rmation are
being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and
utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs,
to protect the Government’s financial interest, and to verify the accuracy of the information you provide. This information may be released to
appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the
information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide
all of the information requested by the HA, including all Social Security Numbers you, and all other household members age si x years and
older, have and use. Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not
providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay
or rejection of your eligibility approval.
Penalties for Misusing this Consent:
HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosu res or improper uses of
information collected based on the consent form.
Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any per son who knowingly or willfully
requests, obtains or discloses any information under false pretenses concerning an appl icant or participant may be subject to a misdemeanor and fined not more
than $5,000.
Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek oth er relief, as may be appropriate,
against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.
Original is retained by the requesting organization.
ref. Handbooks 7420.7, 7420.8, & 7465.1
form HUD-9886 (7/94)
AUTHORIZATION FOR RELEASE OF INFORMATION
CONSENT
I authorize and direct any federal, state or local agency, organization, business, or individual to release to the
Houston Housing Authority any information or materials needed to complete and verify my application for
housing assistance and/or to maintain my continued occupancy of housing furnished by or through the
Housing Authority. I understand and agree that this authorization or the information obtained with its use
may be given to and used by the Housing Authority in administering and enforcing program rules and policies.
I also consent for HUD or the Housing Authority to release information from my participant file related to my
rental history to credit bureaus, collections agencies and/or future landlords. This includes records on my
payment history, and any violations of my lease or PHA policies.
I authorize the Houston Housing Authority to release to any entity or person any information relating to me if
the Houston Housing Authority determines that releasing such information might lead to additional assistance
being provided to me.
INFORMATION COVERED
I understand that, depending on program policies and requirements, previous or current information
regarding my household or me may be requested; this includes but is not limited to:
Identity and Marital Status
Medical or Child Care Allowances
Employment, Income, and Assets
Residences and Rental Activity Income
Credit and Criminal Activity
I understand that this authorization cannot be used to obtain any information about me that is not pertinent
to my eligibility and continued participation in a housing assistance program.
GROUPS OR INDIVIDUALS THAT MAY BE ASKED
The groups or individuals that may be asked to release the above information (depending on program
requirements) includes, but not limited to:
Previous Landlords (including
Public Housing Agencies)
Law Enforcement Agencies
Support and Alimony Providers
Utility Companies
Medical and Child Care Providers
Veteran’s Administration
Welfare Agencies
Schools and Colleges
Credit Bureaus and Providers
Mortgage Companies
Retirement/Pensions
Courts and Post Offices
Social Security
Administration
Lending Institutions
COMPUTER MATCHING NOTICE AND CONSENT
I understand and agree that the Housing Authority may conduct computer-matching programs to verify the
information supplied for my application or re-examination. If a computer match is done, I understand that I
have a right to notification of any adverse information found and a chance to disprove incorrect information.
HUD or the Housing Authority may, in the course of its duties exchange such automated information with
other federal, state, or local agencies, including but not limited to State Employment Security agencies;
Department of Defense; Office of Personnel Management; U.S. Postal Services; Social Security Agency; and
State Welfare and food stamp agencies.
Page 1 of 2
CONDITIONS
I agree that a photocopy of this authorization may be used for the purposes stated above. The original of this
authorization is on file with the PHA and will stay in effect for a year and three months from the date signed. I
understand I have a right to review my file and correct any information that I can prove is incorrect.
Signature(s)
Printed Name
Date
Head of Household
Spouse/Co-Head
Adult Member
NOTE: This general consent may not be used to request a copy of a tax return. If a copy of a tax return is
needed, IRS Form 4506, “Request for a copy of a tax form” must be prepared and signed separately.
Page 2 of 2
HOUSEHOLD ASSETS SELF - CERTIFICATION
(An asset is something of value that can be converted to cash)
1. Does any member of your family have ACCESS to any of the following?
Savings Account………………………..
Checking Account………………………
 Yes
 Yes
 No
 No
Certificate of Deposit…………………….
Money Market Account………………….
 Yes
 Yes
 No
 No
Explain any “Yes” answers below.
Family Member Name
Bank Name
Account Number
Balance
1.
2.
3.
4.
2. Does any member of your family own or have access to any of the following?
Stocks. ………………………………………  Yes
Bonds. ……………………………………….  Yes
Real Estate (Property/Land). ……………  Yes
Trust Funds. …………………………………  Yes
Pensions. ……………………………………  Yes
 No
 No
 No
 No
 No
 No
Individual Retirement Account (IRA)…..  Yes
 No
Inheritances. …………………………………  Yes
 Yes
 No
Life Insurance Policies. …………………………………
 Yes
 No
401K or 403B Accounts. ………………………………
 No
Any other type of Capital Investment….  Yes
Explain any "Yes" answers below.
Family Member Name
Type of Asset
Account Number
Value
3. Is the value of any asset that you answered yes to above $5,000? _____Yes _____ No
IF YOU ANSWERED YES TO ANY QUESTION ABOVE ABOUT ASSETS AND THE VALUE IS OVER $5,000 YOU ARE REQUIRED
TO PROVIDE THE MOST RECENT MONTHLY OR QUARTERLY STATEMENT FOR EACH ASSET.
1of 2
Certification of Information
WARNING: TITLE 18, SECTION 1001 OF THE UNITED STATES CODE STATES THAT A PERSON IS GUILTY OF A FELONY
FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR
AGENCY OF THE UNITED STATES AND SHALL BE FINED NOT MORE THAN $10,000 OR IMPRISONED FOR NOT MORE
THAN FIVE YEARS OR BOTH.
I hereby certify that all of the information I have provided on this reexamination form is true and complete.
Signature of Head of Household
Date
Signature of Spouse or Co-head
Date
Current Phone Number
Name & Phone Number of an
Emergency Contact
Email Address
2 of 2
Housing Choice Voucher Program
REGULAR CONTRIBUTIONS & GIFTS
has stated that you assist him/her in support of their family.
(Print Name of Client)
 The following Contribution form provided with this document is to be filled out by the
person who provides assistance to the client listed above in support of his/her family.
 The person completing this form must sign and print their name and list their relationship
to the client listed above.
 You must complete this form listing dollar amount(s) next to the area you provide support.
 If you pay Child Support that has not been ordered by the court, indicate what means of
support you provide.
 If you are supporting the above client until they are able to provide their own means of
income, identify the means of support that best describes the support that you provide on
the following documents.
PLEASE MAKE CERTAIN YOU READ AND UNDERSTAND THE ABOVE INFORMATION BEFORE YOU
COMPLETE AND SIGN THE ATTACHED FORM.
1 of 2
Housing Choice Voucher Program – Regular Contributions & Gifts
Certification
I,
, certify that I contribute the following items to
(Name of person providing contribution)
,
(Print name of Client)
in support of their family.
ITEM
AMOUNT
WEEKLY
$
$
MONTHLY
Cash:
Rent:
Utilities:
Electric
Gas
Water/Sewer
Phone
Groceries:
Personal Hygiene Products:
Child Care:
Automobile:
Gas
Oil
Repairs
Notes
Insurance
Bus Fare Transportation:
Health:
Life
Medical
Dental
Legal:
Clothing:
Laundry/Dry Cleaning:
TOTAL:
$
_______
Signature of Individual Providing Contribution
Relationship to Client
Date
_____________________________
Address
Phone number
E-mail
WARNING * Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or
misrepresentation to any Department or Agency of the United States as to matters within its jurisdiction.
2 of 2
CRIMINAL BACKGROUND CHECK RELEASE FORM
Este formulario está disponible en español a petición.
The Houston Housing Authority (“HHA”) requires all applicants or participants (Head of Household and listed household members)
18 and older to submit to a criminal background screening. The background screening may be conducted prior to admission, at any
recertification, prior to moves, or at any time relating to any alleged criminal violation for the purposes of determining your initial or
continuing eligibility. HHA will exercise all rights according to HUD guidelines to deny, terminate and/or evict any applicant or
participant who fails the background screening according to HHA policies and procedures. Federal law also requires you to
cooperate by supplying information regarding the criminal activity of any adult members of your household. False answers and/or
failure to list all arrests, convictions or pending criminal charges are cause for disqualification, termination and/or eviction from
HHA’s programs.
***Warning: 18 U.S.C. 1001 provides that any individual who, knowingly and willfully falsifies, conceals, or covers up a material fact,
or; makes any materially false, fictitious, or fraudulent statement or representation; or makes or uses any false writing or document
knowing the same to contain any materially false, fictitious, or fraudulent statement or representation; or makes or uses any false
writing or document knowing the same to contain any materially false, fictitious, or fraudulent statement or entry shall be fined no
more than $10,000 or imprisoned for not more than five years, or both.
Last Name: _____________________________________ First Name: __________________ Middle Name: ___________________
Date of Birth: ____/ ____/ ____ SS# _____/ ____/ _____ DL or ID# ___________________________________________________
1. Have you ever been evicted or terminated from Public Housing and/or a subsidized housing program for engaging in drug related
or other criminal activity? (__) YES
(__) NO
2. If you answered “YES” to Question No. 1, please describe each instance here: (Use additional pages if necessary)
Housing Authority
Reason for Termination and/or Eviction
3. Have you been arrested or convicted within the past 5 years, or do you have any pending criminal charges?
(__) YES
(__) NO
4. If you answered “YES” to Question No. 3, please list each arrest, conviction and/or pending criminal charges here:
(Use additional pages if necessary)
Date of Offense
City/County/State
Charges
5. Have you ever used any name other than your birth name or married name? (___) YES
Penalty
(___) NO
6. If you answered “YES” to Question No. 5, please list any other names you have ever used here: (Use additional pages if necessary)
1.
3.
2.
4.
I certify that the above information and answers provided are true and correct. I also understand that if any of this information is
found to be false or incomplete, my application, participation and/or lease may be terminated at any time. I authorize HHA to
conduct a criminal background check to verify my statements on this form and my eligibility for HHA’s programs.
___________________________________________________
Applicant/Resident Signature
______________________________________________________
Date
(For Office use only) Client #____________________________ Requested by Housing Specialist ____________________________
Rev. 05.12
Housing Choice Voucher Program
Declaration of U.S. Citizenship or Non Citizens with Eligible Immigration
Status and Immigration Status Release of Evidence
I,
, certify, under penalty of perjury, that, to the best of my
knowledge, I am lawfully in the United States because:
(Check appropriate box)
I am a citizen, naturalized or national of the United States:
I am not a citizen or national of the United States nor do I have eligible immigration status.
I have eligible immigration status as defined in the Immigration and Nationality Act (INA) or 1952
and have provided appropriate documents proving that status:
Immigrant status [INA Sections 101(a) (15) or 101(a) (20)]
Permanent residence [INA Section 249]
Refugee, asylum or conditional entry status [INA Sections 207, 208, or 203]
Parole status [INA Section 212(d) (5)]
Threat of life or freedom under [INA Section 243(h)]
Amnesty [INA Section 249A]
I hereby grant my consent for Houston Housing Authority to release evidence of my eligible immigration status
without responsibility for the further use or transmission of the evidence by the entity receiving it to:
A. The Department of Housing and Urban Development (HUD) as required by HUD;
B.
The U.S. Citizenship and Immigration Services (USCIS) for purposes of verification of the Immigration
status of the individual named on this form.
This notice is required to inform you that it is possible that the evidence of eligible immigration status may be released by
HUD. Evidence of eligible immigration status shall only be released to the USCIS for purposes of establishing eligibility for
financial assistance and not for any other purpose. HUD is not responsible for the further use or transmission of the
evidence or other information by the Houston Housing Authority as required by HUD and the USCIS for purposes of
verification on the immigration status of the individual.
Date
Signature
Signature for Minor or Relationship
For children under the age of 18, the release of evidence form must be signed by the responsible adult who will reside in
the unit.
WARNING: 18 USC 1001 provides that whoever knowingly and willfully makes or uses a document or writing containing any false,
fictitious, or fraudulent statement or entry in any matter within the jurisdiction of any department or agency of the United States,
shall be fined not more than $10,000 or imprisoned for not more than five years, or both.
Housing Choice Voucher Program
Lead Base Paint Questionnaire
FILL OUT AND RETURN
Name: _________________________________________________ Client Status:
Housing Choice Voucher Client #: ______________________
Active
Searching
Date: _______________________
1. How many children in the household are under the age of 6? __________________
2. Are there any children under the age of 6 in the household with an Environmental Intervention Blood
Lead Level (Lead Poisoned Child)? ______________________
3. If YES to question #2, please GIVE THE NAME, BIRTHDATE AND GENDER of the child or
children under the age of six (6) with an Environmental Intervention Blood Lead Level:
Child’s Name
Date of Birth
Gender
(F = Female & M = Male)
Head of Household: _____________________________________ Date: ______________________
(Signature)
THIS QUESTIONNAIRE DOES NOT GO TO THE AGENT/OWNER OR LANDLORD
For Houston Housing Authority Employees to Complete ONLY:
Occupancy Technician: ___________________________________
Program Type: ____________________________________________
TEXAS WORKSOURCE UNEMPLOYMENT BENEFITS SERVICES
Customer Service
1-800-939-6631
Tele Center is available Monday - Friday 7am – 6pm to speak to a customer service representatives regarding
question such as:
-How to apply for unemployment benefits?
-What is the status of my claim?
-How can I retrieve my information online?
-I am missing a form, how can I retrieve another copy of a document that was mailed to me?
-I got laid off can I still apply for benefits?
-When did my benefits end?
-When can I expect to receive my first unemployment benefits check?
How to apply for unemployment benefits online using the TWC website
Go to TWC Website
http://www.twc.state.tx.us/
From the main page go to the Quick links section and clink on Unemployment Benefits Services
On the next page choose one of the following Log in options:
-Returning User
-Sign Up for a TWC Internet User ID
Direct Link
https://services.twc.state.tx.us/UBS/security/logon.do
-Enter user ID and password and click the Logon button
COMMUNITY RESOURCES
The following agencies are great resources that offer unique and valuable services that everyone should know about.
Only the agencies themselves can tell you whether or not you qualify and the programs they offer can change anytime.
United Way of Greater Houston
M
Windsor Village Social Services
M
713-957-HELP
2-1-1
713-551-8792
Harris County Social Services
M
Gulf Coast Community Svcs Central
M
713-696-7900
Houston Area Community Services
M
713-426-0027
Salvation Army Houston Area
M
713-658-9205
Asian American Family Services
M
713-600-9400
West Houston Assistance Ministries
M
713-977-9942
Cypress Assistance Ministries
M
Southeast Area Ministry
M
281-955-7440
Humble Area Assistance Ministries
M
New Hope Counseling Centers
M
281-446-3663
Brentwood Project WAITT
M
713-852-2551
City of Houston Office of Veterans Affairs
M
832-393-0092
Dispute Resolution Center
713-755-8274
Link Up America/Lifeline
U
Houston Area Women’s Center
M
713-528-6798
Texas Attorney General Child Support Division
S
800-252-8014
TWC- Child Care Assistance
S
713-334-5980
Harris County Public Health WIC program 713-407-5800
F
713-944-0093
Lite UP Texas
U
1-866-454-8387
713-393-4700
281-446-3363
1-866-454-8387
Sign Language Accessible Interpreters
713-263-8299
SER Jobs for Progress of the Texas Gulf Coast
E, J
713-773-6000
Operation Jobs
E, J
281-955-5895
Career and Recovery Resources, Inc.
E, J
GCCS-JD Walker Multi-Service Center
E, J,
281-426-4757
Way to Work Car Loan Program
T
713-861-4849
Fair Haven Food Pantry
F
713-467-4363
Harris County Rides
T
METRO www.ridemetro.org
T
SNAP- Food Benefits
F
Social Security Administration
Key :
J- Jobs
E- Education
713-754-7000
713-368-7433
713-635-4000
1-877-541-7905
800-772-1213
U-Utilities
S- Shelter
Houston Food Bank Hotline
F
832-369-9390
Money Management International
866-889-9347
D
H- Health
F- Food
D-Debt and Budget Counseling
T-Transportation M-Multiple Resources S-Support Services
Interim Change of Family Composition FAQ
Q1. Can I add my child or relative to the household who is over 18 years of age?
A. You can submit the request to add with all required documents and wait for the decision. However HHA is not
required to add on an adult.
Q2. I would like to add on my grandchild to my household who is under the age of 18? What documents
will I need?
A. You must provide a court award showing you have legal custody of the child along with copies of the birth
certificate and social security card. We will not accept a notarized letter or letter from the parent of the child.
Q3. I recently got engaged and would like to add my spouse to my household when we get married? Is this
allowed and what documents will I needed?
A. You can submit a request to add your spouse to your household and must report that change within 10 days.
Before allowing anyone to move into your unit other than birth, legal adoption or court awarded custody;
they must be approved by the Houston Housing Authority and your landlord . Failure to receive
approval from HHA in advance could result in termination of assistance
Q4. I would like to remove a child who is under age of 17 from the household. What documents should I submit?
A. If your child has income such as Social Security, Social Security Disability, or Child support. You must submit
the required documents showing the new beneficiary, a written letter and proof of address for the person
the child resides with.
B
To remove a family member that is under the age of 18 with no income you must submit the Change of Family
Composition packet. There are no other required documents needed.
Q5. How will I know that my request for a change in family composition is complete?
A. If you are approved for a Change in Family Composition an approval letter will be mailed to you and to the
landlord. If your request has been denied a denial letter will be mailed to you and your landlord within 30 days.