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LIST THE HOUSEHOLD MEMBERS TO BE COVERED (please print): If you have additional members, please attach a separate list. Name: Date of Birth (Month, Day, Year): Social Security No.: Name: Date of Birth
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How to Fill Out List Form Household Members:

01
Start by writing the heading "Household Members" at the top of the form.
02
Begin by listing the names of all individuals who reside in your household.
03
Include their full names, including first, middle, and last names.
04
Next, provide their relationship to the primary applicant or head of the household.
05
Specify the age of each household member. Include infants, children, adults, and senior citizens.
06
If applicable, indicate any special circumstances or needs for certain members, such as disabilities or medical conditions.
07
Review the form for accuracy and completeness. Make sure all information is legible and correctly entered.
08
Sign and date the form once all necessary information has been provided.

Who Needs List Form Household Members:

01
Individuals applying for government assistance programs, such as housing or food assistance, may need to fill out a list form household members.
02
Landlords or leasing agencies may require potential tenants to provide a list form household members when applying for rental properties.
03
Insurance companies might request a list form household members to determine eligibility and coverage for a specific policy.
Overall, individuals and organizations requiring accurate and up-to-date information about all members residing in a specific household would benefit from utilizing a list form household members.

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