Tribal Emergency Home Repair Application ONE TIME ASSISTANCE WITHIN 12-MONTHS

Tribal Emergency Home Repair Application ONE TIME ASSISTANCE WITHIN 12-MONTHS

Complete application thoroughly
Applicant Name:*

First NameLast Name
DOB:*

MonthDayYear
Date
Email*
example@example.com
Roll#*
Copy of CDIB Card:*

Cancelof
Physical Address of Home:*

Street Address

CityState / Province

Postal / Zip Code
County:*
Current Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location Coordinates
Home Status:*

OwnedDept. of Housing
Homeowner proof of ownership:*

Proof of Ownership must be submitted with application. Example-Deed, Title, (TSR)-Title Status Report
Cancelof
Children in Home:*

YesNo
Contact Number:*
Message Number:*
Elder

YesNo
Brief description of needed emergency home repairs:*
PROGRAM GUIDELINES

Partnership Services
Housing Authority: An Emergency Home Repair is defined as a water leak in the supply or drain and waste lines, conditions of electrical fire, HVAC break down, dangerous or life threatening issue, or health related issue that requires immediate attention. Only enrolled members of the Cheyenne and Arapaho Tribes are eligible to receive assistance in the SERVICE AREA. If the applicant qualifies for assistance from the Housing Authority MEPA Funds, Housing will coordinate the repairs using established policies. If the applicant does NOT qualify for assistance from Housing, the applicant will be referred to the appropriate program to coordinate approved repairs using applicable guidelines. No reimbursement for repairs will be provided after work has been completed. Emergency Home Repair Assistance will be provided ONLY once in a 12 month period. Failure of the homeowner's maintenance responsibility may disqualify an application. Work will conform to applicable local and state building codes. Proof of Ownership must be submitted with application. Example-Deed, Title, (TSR)-Title Status Report
Initials*
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING:

I certify that the information on this application is true and correct to the best of myknowledge. I understand that false information will disqualify my application from consideration. I have read the application for the $1,500.00 Emergency Home Repair Service and agree to the terms and conditions once every 12-months
Applicant Signature:*

Clear
Date

MonthDayYear
Date
OFFICIAL USE ONLY

---------------------------------------------------------------------

____ Application received by Tribal Home Repair Program

Date Received: ______________ Initial ______

____ Application forwarded to Dept. of Housing

Date Received: ______________ Initial ______

Action taken by Dept. of Housing:

ELIGIBLE FOR MEPA FUNDS: YES/NO

ELGIBLE CHG BK AGMT: YES/NO

Dept. of HOUSING

TO PERFORM EMERGENCY REPAIRS: YES/NO

FWD TO Tribal Home Repair: YES/NO
Should be Empty:

Tribal Emergency Home Repair Application ONE TIME ASSISTANCE WITHIN 12-MONTHS

PROGRAM GUIDELINES

PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY BEFORE SIGNING: