Chemung County, NY · Chemung County
Residency & Household Composition Verification
This form records who lives in a dwelling and is used by applicants or recipients to verify residency and household composition for county assistance cases.
At a glance
- Issued by
- City of Chemung County · Chemung County, Chemung County, New York
- Notarization
- Not required: file this form without a notary.
- Official source
- chemungcountyny.gov
- Blank form
- Download the PDF
- Catalogued
- Machine-readable
- JSON record · about the forms index
What this form is
The form lists people residing in a dwelling, their relationships, and whether any children are visiting. It requires verification by people who are not on the application or case: two signatures for PA, or one for SNAP or Medicaid. Verifiers provide printed names, signatures, dates, and phone numbers, and applicants or recipients also sign and date the form.
Who needs it
Applicants or recipients completing a residency and household composition verification for PA, SNAP, or Medicaid cases need this form.
How to submit it
Submit it to the county office named on the form; check the county website for current contact details.
About notarization
This document is signed without a notary; it requires signatures from people not on the application or case, plus applicant or recipient signatures and dates.
How to submit this form
- 1
Download the Form
Download the Residency & Household Composition Verification PDF.
- 2
Complete Household Details
List the people residing in the dwelling, their relationships, visiting-child status, and the dwelling address.
- 3
Gather Required Signatures
Have the required number of people not on the application or case verify and sign; applicants or recipients also sign and date.
- 4
Submit to the County
Submit the completed form to the county office named on it; check the county website for current contact details.
Frequently asked questions
- What information does the Residency & Household Composition Verification request?
- It asks for the names and relationships of people residing in the dwelling, whether a child is visiting, the address, verifier details, and applicant or recipient signatures.
- Do I need a notary for the Residency & Household Composition Verification?
- No. This document is signed without a notary. It requires signatures from people not on the application or case, plus applicant or recipient signatures and dates.
- How do I submit the Residency & Household Composition Verification?
- The form does not give submission instructions. Submit it to the county office named on the form; check the county website for current contact details.