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ANAHEIM HOUSING AUTHORITY ANAHEIM WEST TOWER 201 S. ANAHEIM BLVD., SECOND FLOOR, ANAHEIM, CA 92805 (714)765-4320 FAX (714)765-4331 Household Composition Change Form Warning! Section 1001 of Title 18 of the US Code makes it a criminal offense to make any willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction punishable by fine not to exceed $250,000 and/or imprisonment of not more than 5 years. Instructions: Use this form to report all changes in household composition (someone moving in or out). Household composition changes must be reported within 10 days of occurrence. Identifying Information Your Social Security Home Phone Number Alternate Phone Housing Specialist’s Name Request to Add a New Household Member I am requesting to: Add a household member AHA must approve any new household members before they join the household. Adults must pass a criminal background check. Name of Person Birthdate CA ID/DL# Social Security # Relationship Move-in Date Adults requesting to be added must consent to criminal background check by signing below. . Signature of new household member* Date Removing a Household Member I am requesting to: Remove (AHA may require proof of move out) Name of Person Birthdate Relationship Move-out Date New Address: Additional Information I certify that the information I have provided above is complete and accurate. Head of Household Date If you have not received an acknowledgement of your reported change(s) from the Housing Authority within 14 days, please contact your Housing Specialist to ensure that your form has been received.