(This form must be notarized if changing your address, or attach a copy of your drivers license for review and verification review. The HA will send a confirmation letter)
Please list members other than yourself you wish to be part of your household, attach another sheet if necessary.
Date of Birth: Relationship:
963 Montauk Hwy, Oakdale, NY 11769 Phone: (631) 589-7100 Fax: (631) 589-6575 Hearing/Speech Impaired Dial 7-1-1 (NY Relay) www.IslipHousing.org