CHANGE OF HOUSEHOLD COMPOSITION PACKET INSTRUCTIONS TO REMOVE A MEMBER
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- Héctor Rey Redondo
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1 CHANGE OF HOUSEHOLD COMPOSITION PACKET INSTRUCTIONS TO Participant: REMOVE A MEMBER In an effort to ensure you and your household are served in a timely manner, we are requesting that you completely fill out and sign every document in the enclosed packet within 10 days. Warning: Failure to report a change of income or household composition in writing within 10 days could result in the termination of your housing assistance. To remove a member of your household, you must enclose the following: a. Statement providing new address information for each household member being removed Complete and return all the attached forms: a. COFC Removal Form b. Statement stating the change you are requesting Failure to submit the required documentation may delay your request to remove a member to your household. It is the policy of the San Antonio Housing Authority to provide services without regard to race, color, religion, national origin, ancestry, age, sex, sexual orientation, gender identity, familial status, physical handicap, or disability. Rev. 4/1/2013 Page 1 of 2
2 PAQUETE PARA CAMBIAR LA COMPOSICIÓN FAMILIAR: INSTRUCCIONES PARA LA ELIMINACION DE UN MIEMBRO DE LA FAMILIA Apreciado Participante: Con el fin de asegurar que usted o su familia sean atendidos de manera oportuna, le solicitamos que llene completamente y firme todos los documentos del paquete adjunto dentro de los sigientes10 días laborales al cambio. Advertencia: No reportar algún cambio en los ingresos o la composición de su familia por escrito dentro de los 10 días mencionados anteriormente puede ocasionar la terminación de su asistencia para vivienda. Para eliminar a un miembro de su familia, debe adjuntar lo siguiente: a. Una declaración indicando la nueva dirección del miembro de su familia que se va a eliminar. Llene completamente y devuelva todos los formularios adjuntos: a. Formulario para Eliminar un Miembro de la Familia (COFC Removal Form) b. Declaración indicando el cambio que está solicitando No enviar la documentación requerida puede retrasar su solicitud para eliminar a un miembro de su familia (210) para asistencia. Rev. 4/1/2013 Page 2 of 2
3 CHANGE OF HOUSEHOLD COMPOSITION REMOVE A MEMBER FORM Please complete this form and submit it to the SAHA before permitting anyone to move into your housing unit. You must report any changes in household composition in writing within 10 business days of the change. Head of Household:. Date: SSN:. Home Phone:. Cell Phone: Address: City: State: Zip: Household Member Being Removed from the Unit Name: Move-out Date: New Address:. City:. State: Zip: Contact Phone: By signing below, I certify that the information provided is true and correct. I understand that giving false or inaccurate information may jeopardize my eligibility to receive future assistance. Signature: Date: (210) para asistencia. Rev. 4/1/2013 Page 1 of 2
4 CAMBIO EN LA COMPOSICIÓN FAMILIAR: FORMULARIO PARA LA ELIMINACION DE UN MIEMBRO DE LA FAMILIA Por favor llene este formulario y remítalo a SAHA antes de permitir que cualquier miembro de su familia se mude de la unidad de vivienda. Usted debe reportar cualquier cambio en los ingresos o la composición de su familia por escrito dentro de los siguientes10 días laborales al cambio. Cabeza de Familia:. Fecha: Seguro Social:. Teléfono de su casa.: Celular: Dirección: Ciudad: Estado: Cód. Postal: Información de la Persona que Desea Eliminar de la Unidad Nombre:. Fecha de salida: Nueva Dirección: Ciudad:. Estado: Código Postal: Número telefónico: Al firmar a continuación, declaro que la información provista es correcta. Comprendo que al dar información falsa o inexacta puede comprometer mi elegibilidad para recibir asistencia en el futuro. Firma: Fecha: (210) para asistencia. Rev. 4/1/2013 Page 2 of 2
5 STATEMENT FORM Name (please print): Date: SSN: Home Telephone: Work Telephone: Unit Address: City: State: Zip Code: Statement (please print): Warning: 18 U.S.C provides, among other things, that whoever knowingly and willfully makes or uses a document in writing containing false, fictitious or fraudulent statements or entries in any matter within the jurisdiction of a department or an agency of the United States shall be fined not more than $10,000 or imprisoned for not more than five years or both. By signing below, I am certifying that the information above is true and correct. I also acknowledge that it is my responsibility to report any and all of the changes in the income and/ or family composition of my household within ten days of the change in writing. Signature: Date: In the presence of (name and signature): (210) para asistencia. Rev. 3/27/2013 Page 1 of 1 AHP-9310
6 FORMATO PARA DECLARACIONES Nombre (en letra de molde): Fecha: Núm. del Seguro Social: Teléfono de su Casa: Correo Electrónico: Teléfono del Trabajo: Dirección de la Unidad: Ciudad: Estado: Código Postal: Declaración (en letra de molde): Advertencia: Según el artículo 18 U.S.C. 1001, cualquier persona que intencional y voluntariamente remita información falsa, ficticia o fraudulenta por escrito sobre cualquier asunto a cualquier dependencia del Gobierno de los Estados Unidos, será sujeta a una multa no mayor a los $10,000, su encarcelamiento por no más de 5 años, o a ambas penalidades. Al firmar a continuación, declaro que la información que he proporcionado es completa, verdadera y exacta. Así mismo, reconozco que es mi responsabilidad reportar por escrito todos y cada uno de los cambios en los ingresos y la composición de mi familia dentro de diez días a partir de la fecha en que ocurrió dicho cambio. Firma: Fecha: Ante la presencia de (nombre y firma): (210) para asistencia. Rev. 3/27/2013 Page 1 of 1 AHP-9310-SP
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