Low-Income Housing Application

Northern Ponca Housing Authority

Low-Income Housing Application
Dear Applicant,

Northern Ponca Housing Authority (NPHA) is the Tribally-Designated Housing Entity (THDE) created by The Ponca Tribe of Nebraska to provide low-income housing for federally-recognized enrolled Native American families.

To qualify for low-income housing, an application must be submitted to NPHA. To ensure that your application is processed in a timely manner, be sure to submit all requested documentation along with the completed application. NPHA does not offer any emergency housing programs, units are awarded through a point-based waiting list. NPHA will attempt to contact applicants one time only for remaining information, missing information/documentation not received within 30 days of NPHA’s request will result in the application being rejected.
Application Checklist
Checklist for a completed NPHA Low Rent Housing Application:

Completed NPHA Low Income Housing Application FormSocial Security Cards: Provide copies of Social Security Cards for all household members.Legal guardianship documents for all dependents I.E. birth certificates, legal power of attorney, courtTribal enrollment: Provide copies of tribal enrollment for all Native American members on theIncome Verification: Provide proof of income of all household members, 18 years or older one month ofThe Release of Information Authorization must be completed and signed by all members of theCompleted applications may be mailed, faxed, e-mailed or delivered in person to the NPHA office located at 1501 West Michigan Avenue, Norfolk, NE 68701. 1. Fax Number: (402)379-8557 2. E-Mail Address: NPHA@Poncahousing.org
This application will not be processed until all information requested has been completed, submitted, and verified.

Applicant name: (Head of household must be 19 years of age or older.)
First*
MI
Last*
Other names used other than above:
Contact Information:
Address*

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*
or Message Number
Email Address:
example@example.com
Emergency Contact Person:*
Phone Number:*
Service Area applying for (only check one county):
Nebraska : Douglas (Omaha)Nebraska: Lancaster (Lincoln)Nebraska: Knox (Niobrara)Nebraska: Madison (Norfolk & Battle Creek)Nebraska: Platte (Columbus)Nebraska: Sarpy (Bellevue)Iowa: Pottawattamie (Council Bluffs)Iowa: Woodbury (Sioux City)
HOUSEHOLD COMPOSITION

	Name	Relation to HOH	Gender F/M	DOB	Social Security #	Tribal affiliation and enrollment #
1
2
3
4
5
6

Please provide the following documents: Tribal Enrollment/Certificate of Blood, Social Security Cards for all household members, and legal guardianship documents for all dependents (i.e. birth certificates, legal power of attorney, foster care, etc.)*

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If you wish to add someone not already on your composition, call the A&O counselor for more information.
Is anyone on the composition disabled as defined by 24 CFR Part 1000.10?*
If so, please provide a copy of Social Security Disability (SSD) or Supplemental Security Income (SSI) benefit statement.

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If elderly and/or disabled, please list monthly medical expenses anticipated to be paid out of pocket by the composition and not reimbursed by an outside source such as insurance, Medicare, charitable organizations, etc.
Does one or more of the adults listed on the composition have 100% legal custody of all dependents on the composition?*
If no, please explain
Did anyone on the composition serve in the U.S. Armed Forces and that was honorably discharged?*
If yes, please provide a copy of the form DD-214.

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Do you anticipate any change in your household composition during the next 12 months?*
If yes, please explain:
What is your current living situation?
How much do you currently pay for rent?
Have you previously rented from Northern Ponca Housing Authority or any other Tribal Housing Authority? If yes, when and where*
ll. BACKGROUND
Has anyone on the composition ever been convicted of a crime? Please explain.*
lll. HOUSEHOLD INCOME

	Name	Source of Income	Wage per hour	Hours per week	Monthly income received

Please submit income verification via tax return, check stub, TANF statement, etc. Income statements must be the most recent income and applicant must provide at least one month of income statements.*

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Does anyone on the composition pay child care expenses in order to be gainfully employed and/or further their education (disregard if reimbursed for this expense)?*
Does anyone on the composition have educational and/or work-related travel expenses equal to or more than 60 miles per day (disregard if reimbursed for this expense)?*
Does anyone on the composition own land and/or a home?*
If yes, what will happen to this property should NPHA award you a unit?
It is the applicant's responsibility to immediately notify NPHA of any changes in family composition, income and/or contact information. NPHA requires that all applicants re-certify at least annually. If the information is not received within 30 days, the applicant will be removed from the waiting list and will have to start the application process over if they wish to be reconsidered for the waiting list. Before being awarded a unit, NPHA will re-certify the tenant's income, as well as perform a criminal background check and landlord reference check; applicants may be declined due to unfavorable results, applicants denied have the opportunity to appeal. Being on the waiting list is not a guarantee that the applicant will eventually be awarded a unit.

I/We certify that all information given to NPHA is accurate and complete to the best of my/our knowledge and belief. I/We also understand that false statements and/or information are grounds for termination of housing assistance and termination of tenancy.
Signature Head of Household:*

Clear
Date:*

MonthDayYear
Date
1501 W. Michigan Ave, Norfolk, NE 68701 1501 W. Michigan Ave, Norfolk, NE 68701

P: 402-379-8224, F: 402- 379-8557 P: 402-379-8224, F: 402-3 79-8557

www.poncahousing.org, npha@poncahousing.org www.poncahousing.org, npha@poncahousing.org
Northern Ponca Housing Authority
RELEASE OF INFORMATION AUTHORIZATION
Date

MonthDayYear
Date
I/We authorize the above-named agency to obtain information about me or my household that is pertinent to eligibility for participation in assisted housing programs.

This may include rental history, financial and credit reports, private or public benefit information, criminal activity reports, employment verification, medical or child care expenses, family composition, or handicapped assistance expenses.

I/ We agree this Authorization may be photocopied and used up to one year from the date above for the following items: recertification for public housing or rental assistance programs.

I/We authorize NPHA and its staff to share and/or obtain any pertinent and/or necessary information with the Ponca Tribe of Nebraska’s agents and/or assigns.

I/We authorize NPHA and its staff and/or assigns to share any information obtained regarding anyone on the composition, including prospective additions to the composition, with the head of household, as signed below.
If I/we do not sign this Authorization, I/we also understand that my/our program assistance may be denied or terminated.
Head of Household Signature*

Clear
Printed Name*
XXX-XX last 4 digits of Social Security Number*
Other Adult Signature

Clear
Printed Name
XXX-XX last 4 digits of Social Security Number
Other Adult Signature

Clear
Printed Name
XXX-XX last 4 digits of Social Security Number
Other Adult Signature

Clear
Printed Name
XXX-XX last 4 digits of Social Security Number
1501 W. Michigan Ave, Norfolk, NE 68701 1501 W. Michigan Ave, Norfolk, NE 68701

P: 402-379-8224, F: 402-37 9-8557 P: 402-379-8224, F: 402-379-8557

www.poncahousing.org, npha@poncahousing.org www.poncahousing.org, npha@poncahousing.org
Should be Empty:

Northern Ponca Housing Authority

Application Checklist

Contact Information:

HOUSEHOLD COMPOSITION

ll. BACKGROUND

lll. HOUSEHOLD INCOME

Northern Ponca Housing Authority

RELEASE OF INFORMATION AUTHORIZATION