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<br /> Neil S. Gyotoku <br />Housing Administrator <br />Harry Kim <br />Mayor <br />County of Hawaii <br /> <br />OFFICE OF HOUSING AND <br />App# _________ <br />COMMUNITY DEVELOPMENT <br /> <br />EXISTING HOUSING DIVISION <br />1990 Kino`ole Street, Suite 105 -5293 <br />V/TT (808) 959-4642 FAX (808) 959-9308 <br /> <br />CHANGE FORM <br /> <br />Application must be filled out COMPLETELY. Please use BLACK OR BLUE PEN ONLY to complete application. If any question does <br />NOT apply, please acknowledge by writing NONE or NOT APPLICABLE. Do not leave any section unanswered. I am aware that <br />Section 8 is paying for all or part of my rent. I know I MUST REPORT ALL CHANGES WITHIN 10 DAYS. <br /> <br />PLEASE PRINT ALL INFORMATION. <br />GENERAL INFORMATION <br /> EMAIL ADDRESS: __________________________________ <br /> <br />Head of Household: _____________________________________________________________________________ <br /> Legal Last Name First Name MI <br /> <br />Phone Number: Home: _________________ Work: _________________ Other: ______________ <br /> <br />Mailing Address: ____________________________________________________ Apt. No._______________ <br /> <br />City: _____________________________________ State: _____________ Zip: ______________ <br /> <br />PART 1: REQUEST TO ADD FAMILY MEMBERS TO HOUSEHOLD <br />Are you reporting Yes No <br />If you answered YES, please complete the following section. If you answered NO, please skip to Part 2. <br /> <br />NOTE: Birth certificate, social security card, and written permission from your landlord MUST be included with this form. <br />y the household relationship of each adult and child listed. <br />H = Head of Household K = Co-Head (Not Married) Y = Youth Under 18 L = Live In Aide <br />S = Spouse (Married) F = Foster Child/ Adult E = Full Time Student Over 18 A = Other Adult <br /> <br />Last Name & Sr, Jr, etc. First Name MI Date of Birth Sex Relation <br /> <br />H <br /> <br />Race (check one box) Ethnicity (check one box) Social Security Number <br /> <br />\[ \] White \[ \] Asian/Pacific Islander <br />\[ \] Hispanic \[ \] Not <br />\[ \] Black \[ \] American Indian / Alaska Native <br />Hispanic <br />Last Name & Sr, Jr, etc. First Name MI Date of Birth Sex Social Security Number <br />2 <br />Relation <br /> <br />Last Name & Sr, Jr, etc. First Name MI Date of Birth Sex Social Security Number <br />3 <br />Relation <br /> <br />Last Name & Sr, Jr, etc. First Name MI Date of Birth Sex Social Security Number <br />4 <br />Relation <br /> <br />Date family member moved in: __________________________ <br />5072smfd 12/06/2016 <br />EQUAL HOUSING OPPORTUNITY <br />HAWAI`I COUNTY IS AN EQUAL OPPORTUNITY <br />PROVIDER AND <br /> <br />