Metro West Housing Solutions

REQUEST TO ADD OR REMOVE FAMILY MEMBERS

NEW FAMILY MEMBERS MUST BE APPROVED BEFORE OCCUPYING THE ASSISTED UNIT

PART I: TO BE COMPLETED BY THE FAMILY
Head of Household (print): _________________________________________ Last 4 of SSN: _______________
Street Address: ______________________________ City: _________________ State: _____ Zip: ___________
I request to ☐ add ☐ remove (check one) the following family member:
Family Member Name (print): _________________________________________________________________
Family Member SSN: ____________________________ Family Member Date of Birth: _________________
Relationship to Head of Household: _____________________________________________________________
☐ Check here if the new household member is a person with a disability.

I/we agree to provide any documentation necessary to add/remove the above family member. I/we also understand that the landlord must agree and be notified of this change. I/we understand that eligibility for the Housing Choice Voucher Program depends on the results of a criminal background check conducted through the Colorado Bureau of Investigation. I/we authorize Metro West Housing Solutions (MWHS) to conduct a CBI check on all adult members of my household. I/we certify that the information provided is true and correct.

Signature of Head of Household: ________________________________________ Date: _____________
Signature of new/removed adult member: ________________________________ Date: _____________
Signature of Landlord: _________________________________________________ Date: _____________

WARNING: SECTION 1001 OF TITLE 18 OF THE U.S. CODE MAKES IT A CRIMINAL OFFENSE TO MAKE WILLFUL, FALSE STATEMENTS OF MISREPRESENTATION TO ANY DEPARTMENT OR AGENCY OF THE U.S. AS TO ANY MATTER WITHIN ITS JURISDICTION.

PART II: TO BE COMPLETED BY THE PHA
Request to add/remove family member is: ☐ approved ☐ denied
Reason for Denial: ___________________________________________________________________________
☐ No increase/decrease is required per MWHS policy
☐ Increase/decrease of voucher size is approved. New voucher size is: ___________ effective: _____________

ALTERNATIVE FORMATS OF THIS DOCUMENT ARE AVAILABLE UPON REQUEST.

575 Union Blvd Suite 100, Lakewood, Colorado 80228 ● Phone 303-987-7580 ● TTY 711 ● www.mwhs.org