EmailMe Form - HCV: Annual Re-Examination

Name *

First Last

Email

Mobile Phone

### - ### - ####

Home Phone

### - ### - ####

Work Phone

### - ### - ####

Message Phone

### - ### - ####

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Part 1: Household Composition

Please supply the following information for all adults and children that currently lives in the assisted unit. List adults first, then children in order from oldest to youngest. Please use the codes as follows for relation to the head of household for each adult and child listed: H=Head of Household, K=Co-Head, A=Other Adult, F=Foster Child/Adult, Y=Youth Under 18, E=Full Time Student Over 18, L=Live-in Aide.

Head of Household Information *

	Full Legal Name	Date of Birth	Gender	Disabled	Race	Ethnicity (Hispanic/Not Hispanic)
Head of Household

Other Household Members

	Full Legal Name	Relation	Date of Birth	Gender	Disabled	Race	Ethnicity (Hispanic/Not Hispanic)
Member 2
Member 3
Member 4
Member 5
Member 6
Member 7
Member 8

Are you or any adult in the household listed above a part-time or full-time student enrolled in a school of higher education? *

Yes

No

If yes, do you receive financial assistance?

Yes

No

If yes, you will be required to provide proof of enrollment status, a print out from the school of attendance to indicate financial aid assistance you receive by type, and an itemized cost list from the school as well.

Do you wish to move? *

Yes

No

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