King County Housing Authority

CHANGE IN FAMILY SITUATION

The following changes have taken place in my family composition and/or income:

I am Adding Deleting the following family member(s):

I understand that an additional family member may not be added to the lease until the request has been reviewed and formally approved by the Housing Authority and/or Landlord.

List below all sources of income for all members of the household.

If Employed, list the Employer's Name and Address -

List Employment Dates -

Does any Member of your household receive or expect to receive any of the following types of Income? Check all that apply.

List all assets including Checking, Savings, IRA's, Certificates, Stocks, Bonds, etc.

1) Has any member of your family turned 18 years of age since your last review? YES NO
If yes, does that person attend school full time? YES NO
Is this person employed or have any income? YES NO

2) Do you pay Child Care for a family member under thirteen (13) years of age? YES NO
Does the Child Care allow yuo or another family member, over the age of eighteen (18) to work or to attend school? YES NO

I certify that the information given above is true and correct to be the best of my knowledge and belief. I understand that I must report, in writing, any changes in my family income or composition within ten (10) business days of when the change occurred. I am aware that misrepresentation to the Housing Authority of my family's circumstances is considered fraud and is cause for the termination of my housing assistance.

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Signature of Head or Spouse

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Phone Number