Only fill out this form if you are on the wait list and need to report a change. Use this form to report all changes EXCEPT a change of address. See CHANGE OF ADDRESS FORM.
Fill in the required information for you, the Head of Household.
Fill in the information for the household member whom you want to remove.
Fill in or check the required information for each household member you are requesting to add.
I hereby certify under the penalty of perjury that the declarations I have made in this document are true and complete. I understand and acknowledge that any knowing or willful misrepresentations of the declarations (including submission of falsified supporting documentation to support my declarations) contained in this document may result in civil liability and/or criminal penalties, including but not limited to fine or imprisonment, or both under the provision of Title 18 of the United States Code (USC) Section 1001.