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Appendix C <br /> Indian River Habitat for Humanity <br /> Nei,ahborhood Stabilization Pro ram 3 <br /> PERSONAL DECLARATION <br /> This form must be completed in your OWN HANDWRITING- PLEASE PRINT. You must use the legal names fc <br /> each member of your household as it appears on the Social Security Card . ALL ADULT MEMBERS OF TH. <br /> HOUSHOLD MUST SIGN THIS FORM CERTIFYING THE ACCURACY OF THE INFORMATIOI <br /> PERTAINING TO THEM, <br /> II . FAMILY COMPOSITION : List all persons who will be living in your home * List Head of Household First. <br /> Indicate Marital Status as [ S] Single [M] Married [W] Widowed [D] Divorced [C ] Separated <br /> Adult Names Date of Social Relation Marital <br /> Birth Securit # Status <br /> 1 . Self <br /> 2 <br /> 3 . <br /> Children Names Date of Relation School Name Absent Parent Name <br /> Birth <br /> 1 . <br /> 2 . <br /> 3 . <br /> 4 . <br /> 5 . <br /> 6 <br /> T <br /> 8 <br /> 9 . <br /> 10 . <br /> 11 . <br /> 12 . <br /> If separated or divorced, list name & List the "NEXT OF KIN" <br /> Address of spouse/ex- spouse as follows : <br /> Name : Name : <br /> Address : Address : <br /> Social Security Number : Telephone Number : <br /> Relationship : <br />