This form must be signed by ALL adult members of the household and returned to: Autumn House does not discriminate on the basis of disability status in the admission or access to, or treatment, or employment in, its federally assisted programs and activities. Date: Name: Address: City/State/Zip: Phone: FAMILY COMPOSITION List all persons who will be living in your home. (Please remember to include yourself) Family Member Name #1 (First, MI. Last) Birth Date: Social Security Number: Relationship: Age: Sex: Birthplace (City/State): Race: WhiteBlackAmerican Indian or AlaskanAsian or Pacific Ethnicity: HispanicNon-Hispanic Family Member Name #2 (First, MI. Last) Birth Date: Social Security Number: Relationship: Age: Sex: Birthplace (City/State): Race: WhiteBlackAmerican Indian or AlaskanAsian or Pacific Ethnicity: HispanicNon-Hispanic Family Member Name #3 (First, MI. Last) Birth Date: Social Security Number: Relationship: Age: Sex: Birthplace (City/State): Race: WhiteBlackAmerican Indian or AlaskanAsian or Pacific Ethnicity: HispanicNon-Hispanic Anticipated Changes in Family Composition: Have you or any household member resided in any other state(s) YESNO If yes, please list the state(s) and household members that resided in those state(s) below: