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Get Personal Declaration Nysdhcr

BE COMPLETED IN YOUR OWN HANDWRITING, YOU MUST USE THE CORRECT, LEGAL NAME FOR EACH MEMBER OF YOUR HOUSEHOLD. ALL ADULT MEMBERS OF THE HOUSEHOLD MUST SIGN BELOW CERTIFYING THE INFORMATION PERTAINING TO THEM. PLEASE PRINT. I. HOUSEHOLD COMPOSITION: List all persons who will be living in your home, listing head of household first. ADULTS (Legal Names) DATE OF BIRTH RELATIONSHIP TO HEAD OF HOUSEHOLD SOCIAL SECURITY NUMBER 1. INDICATE IF MARRIED (M) WIDOWED (W) SEPARATED (S) DIVORCED (D) YEAR.

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