Request to Add a Household Member

HASB - Housing Authority of South Bend Icon.

Housing Authority of South Bend
Phone: 574.235.9346 • Fax: 574.544.5165
501 Alonzo Watson Dr. • South Bend, IN 46601
Monday-Thursday 8:30 am-5:30 pm (Closed Fridays)

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Anyone you list as a household member must use the subsidized unit as their primary residence (at least 51% of the time). All adults must have an acceptable criminal background, cannot owe any housing authority money, and, if s/he previously participated in a federally subsidized housing program, must have an acceptable compliance history. All adult additions must be approved in writing by your landlord and by the Housing Authority of South Bend before the additional person can move in.

Note: The fields at the bottom of this form marked "For Landlord Use Only" and "For HASB Use Only" should not be completed when submitting this form.

Fields marked with * must be completed or form will not submit.

[{"type":"text","required":true,"label":"Head of Household Name","name":"Head-of-household-name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Head of Household's SSN","name":"head-of-household-social-security-number","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Addition's Name","name":"Additions-name","className":"col-md-6","subtype":"text"},{"type":"text","required":true,"label":"Addition's SSN","name":"Additions-social-security-number","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Step 1: New Member's Information","className":"d-block"},{"type":"text","required":true,"label":"Relation to Head of Household","name":"relation-to-head-of-household","className":"col-md-6","subtype":"text"},{"type":"date","label":"New Household Member's Date of Birth","name":"new-household-members-date-of-birth","className":"col-md-6"},{"type":"radio-group","label":"New Household Member's Gender","name":"new-household-members-gender","className":"col-md-6","values":[{"label":"Male","value":"male"},{"label":"Female","value":"female"}]},{"type":"radio-group","label":"Is the new household member disabled?","name":"Is-the-new-household-member-disabled","className":"col-md-6","values":[{"label":"Yes","value":"yes"},{"label":"No","value":"no"}]},{"type":"radio-group","label":"Is the new household member Hispanic or not Hispanic?","name":"is-the-new-household-member-hispanic-or-not-hispanic","className":"col-md-6","values":[{"label":"Hispanic","value":"hispanic"},{"label":"Not Hispanic","value":"not hispanic"}]},{"type":"text","label":"Race/Ethnicity","name":"race-or-ethnicity","className":"col-md-6","subtype":"text"},{"type":"paragraph","subtype":"p","label":"List all income received and attach 60 days' worth of verification (for example, six paystubs):","className":"d-block"},{"type":"text","label":"Type of Income (#1)","name":"type-of-income-1","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Source of Income #1","name":"source-of-income-1","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Monthly Amount for Income #1","placeholder":"$","name":"monthly-amount-for-income-1","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Type of Income (#2)","name":"Type-of-income-2","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Source of Income #2","name":"source-of-income-2","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Monthly Amount for Income #2","placeholder":"$","name":"monthly-amount-for-income-2","className":"col-lg-4","subtype":"text"},{"type":"paragraph","subtype":"p","label":"List all assets held or owned and attach 60 days' worth of verification (for example, bank or account statements all pages):","className":"d-block"},{"type":"text","label":"Type of Asset (#1)","name":"type-of-asset-1","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Financial Institution of Asset #1","name":"financial-institution-asset-1","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Current Value for Asset #1","placeholder":"$","name":"current-value-asset-1","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Type of Asset (#2)","name":"type-of-asset-2","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Financial Institution of Asset #2","name":"financial-institution-asset-2","className":"col-lg-4","subtype":"text"},{"type":"text","label":"Current Value for Asset #2","placeholder":"$","name":"current-value-asset-2","className":"col-lg-4","subtype":"text"},{"type":"radio-group","label":"Is the new household member a student? (If yes, attach verification of enrollment status, tuition, and financial aid.)","name":"is-the-new-household-member-a-student-if-yes-attach-verification-of-enrollment-status-tuition-and-financial-aid","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"radio-group","label":"Has the new household member ever been convicted of a felony? (If yes, explain below)","name":"has-new-member-been-convicted-of-a-felony","className":"d-block","values":[{"label":"Yes","value":"Yes"},{"label":"No","value":"No"}]},{"type":"textarea","label":"Explanation of felony conviction (if applicable)","name":"explanation-of-felony-conviction-if-applicable","subtype":"textarea","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Step 2: Required Attachments","className":"d-block"},{"type":"paragraph","subtype":"p","label":"For all household additions, the following attachments are required:","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- Legal ID (such as driver's license for adults or birth certificates for minors)","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- Original Social Security number verification","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- Declaration of Citizenship or Immigration Status","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- Non-citizens: Original Homeland Security I-551 or annotated I-94","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- Income, Asset, and Student (if applicable) Verification.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"Additional forms required for adult additions:","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- Authorization to Release of Information (9886)","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- Debts Owed and Terminations (52675)","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- Emergency Contact (92006)","className":"d-block"},{"type":"paragraph","subtype":"p","label":"- What You Should Know About EIV","className":"d-block"},{"type":"file","required":true,"label":"Please upload any attachments required for the new household member (i.e., paystubs, bank or account statements, and any items listed in Step 2).","description":"You may upload up to 20 files (35 Mb max). Files can be PDF, JPG, JPEG format.) Hold CTRL to select multiple files.","name":"please-upload-any-attachmentsrequired-for-the-new-household-member-paystubs-bank-or-account-statements-and-any-items-listed-in-step-2","subtype":"file","multiple":true,"className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"checkbox-group","required":true,"label":"I certify the above information is true and the additional household member will reside in the subsidized unit at least 51% of the time. I acknowledge that falsifying or manipulating information may result in denial or termination from the Voucher program.","name":"I-certify-the-above-information-is-true-and-the-additional-household-member-will-reside-in-the-subsidized-unit-at-least-51-of-the-time-I-acknowledge-that-falsifying-or-manipulating-information-may-result-in-denial-or-termination-from-the-Voucher-program","className":"d-block","values":[{"label":"I have read and agree with the statement above.","value":"I have read and agree with the statement above."}]},{"type":"text","required":true,"label":"Head of Household's Signature","placeholder":"Disclaimer: By typing your name, you are signing this document.","name":"head-of-households-signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature (Head of Household)","name":"Date-of-head-of-households-signature","className":"col-md-6"},{"type":"text","required":true,"label":"New Member's Signature","placeholder":"Disclaimer: By typing your name, you are signing this document.","name":"new-members-signature","className":"col-md-6","subtype":"text"},{"type":"date","required":true,"label":"Date of Signature (New Member)","name":"Date-of-new-members-signature","className":"col-md-6"},{"type":"header","subtype":"h4","label":"Please review the information above and confirm all is accurate. Once reviewed, please use the submit button at the bottom of this form to send this request to HHA.","className":"d-block"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"Landlord Permission (for adult additions only) - FOR LANDLORD USE ONLY","className":"d-block"},{"type":"text","subtype":"disabled","label":"I agree to the addition of this person to the current lease I have with the above-named Voucher-holder. (For LANDLORD use only)","name":"I-agree-to-the-addition-of-this-person-to-the-current-lease-I-have-with-the-above-named-Voucher-holder-for-landlord-use-only","value":"FOR LANDLORD USE ONLY","className":"d-block"},{"type":"text","subtype":"disabled","label":"Landlord Phone Number (For LANDLORD use only)","name":"Landlord-phone-number-for-landlord-use-only","value":"FOR LANDLORD USE ONLY","className":"d-block"},{"type":"text","subtype":"disabled","label":"Landlord Signature (For LANDLORD use only)","name":"landlord-signature-for-landlord-use-only","value":"FOR LANDLORD USE ONLY","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Landlord Signature Date (For LANDLORD use only)","name":"Landlord-signature-date-for-landlord-use-only","value":"FOR LANDLORD USE ONLY","className":"col-md-6"},{"type":"paragraph","subtype":"p","label":"<hr>","className":"d-block"},{"type":"header","subtype":"h4","label":"FOR HASB USE ONLY - Please do not complete the information below.","className":"d-block"},{"type":"text","subtype":"disabled","label":"Recommend - Yes or No (For HASB use only)","name":"Recommend-yes-or-no-for-HASB-use-only","value":"HASB USE ONLY","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Cert. Spec. Initials/Date (For HASB use only)","name":"Cert-specialist-initials-and-date-for-HASB-use-only","value":"HASB USE ONLY","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Background Check - Yes or No (For HASB use only)","name":"Background-check-yes-or-no-for-HASB-use-only","value":"HASB USE ONLY","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Supervisor Initials/Date (For HASB use only)","name":"supervisor-initials-and-date-for-HASB-use-only","value":"HASB USE ONLY","className":"col-md-6"},{"type":"text","subtype":"disabled","label":"Approval - Yes or No (For HASB use only)","name":"Approval-yes-or-no-for-HASB-use-only","value":"HASB USE ONLY","className":"d-block"}]