Loudoun County Department of Family Services
Housing Choice Voucher - Personal Declaration & Affidavit 
HCV Recertification

PLEASE READ CAREFULLY
Complete this form in its entirety and bring it with you to your recertification appointment. If you return it directly to your counselor, please make sure to put their name on the form and /or the envelope to avoid processing delays.
Please note, submission of incomplete declarations and/or failure to disclose full information may result in significant delays. Incomplete declarations will be given back to you for completion. Loudoun County Department of Family Services does not accept responsibility for any loss incurred under these circumstances.
This form must be completed by the applicant. If you are an individual with a disability or other medical need or language barrier, you may have someone assist you.  If you have someone assist you with completing this declaration, that person needs to be listed at the end of the application.
You must use the correct legal name for each member of your household as it appears on the Social Security Card. All adult members age 18 and older, living in the household must sign the declaration certifying the information that pertains to them is correct.
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