DELAWARE COUNTY HOUSING AUTHORITY
1847 Constitution Ave. • P.O. Box 100 • Woodlyn, PA 19094
DO NOT FAX THIS FORM
NO UPDATES WILL BE ACCEPTED BY FAX - ONLY BY MAIL
Date:
_________________________ Appl.# / SS#:
_________________________________
Name:
_______________________________________________________________________
Street
Address: ______________________________________________________________
City:
__________________________State: ______________ Zip Code: ________________
Day
Phone #: ______________ Home Phone: _____________Cell #: _________________
Please
check 1 box that applies to information above:
This is a change
This is an update with
changes
This is an update
****YOU MUST PROVIDE PROOF OF RESIDENCE AND INCOME WITH THIS
UPDATE****
Below
is family member information you must complete if you are adding or deleting
a
member to your application or making other changes indicated.
Family
Member Name: _______________________________________________________
Relationship
to Head of Household ______________________________________________
Birth
Date: __________________ Age: ________ SS#:
___________________________
Birth
Place City_______________________ and State______________________________
Caucasian
African American
American Indian/Alaskan Native
Asian
Other
Add this family
member
Delete this family member
To add a member you must have legal custody of that member and
provide Social Security #, Birth Certificate, and proof of
Custody.
Employment
information must be completed below:
I am no longer employed
Change my employer (list information below)
Employer
Name: _____________________________________________________________
Address:
_____________________________________________________________________
Phone
#: ____________________________
Hrly.
Wage: ______ Annual Salary: ________ Hrs. Worked Per Week:
________ Job Title________
List
any other changes below:
_____________________________________________________