Household update form

All updates to household information need to be submitted in written form. Please use our update form online or send in written responses to 360 Church ST SE, Salem, OR 97305.

Head of Household Name

First Name

Last Name

Household Update Form

Head of Household Middle Initial

Head of Household Month of Birth

Head of Household Day of Birth

Email Address

Phone Number

(###)

###

####

New Address

If you are updating your address, type the new address here. If not, you can leave this section blank.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Other Change?

If there is anything else you need to change or update, please explain below.

Experiencing homelessness?

I am currently homeless.

Yes

Supportive Services?

I am in need of supportive services to maintain my housing.

Yes

Checkbox

By checking this box below, I certify that I am the Head of Household named above, or that I have explicit permission to update household information from the Head of Household. Note: Section 1001 of Title 18 of the U. S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department or Agency of the United States as to any matter within its jurisdiction.

I Agree