HOUSEHOLD COMPOSITION

Tenant Re-Certification Form
1) Tenant Name*
2 Home Phone #
Cell Phone #*
3) Address*
City*
State*
Zip Code*
HOUSEHOLD COMPOSITION

List all individuals who reside in your household*

	Name	Relationship to Head	SS#	DOB	Gender F/M	Tribe Enrolled with and enrollment number
1 (Person filling form)
2
3
4
5
6
7
8
9
10

If you wish to add someone not already on your composition, call your A&O Counselor for more information. Questions 5-9 are for determining income deductions that may lower you rent calculation. Any "yes" responses must be verified.
5) 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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6) 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.
7) Is anyone who isn't the head of household a full-time student? (A student enrolled in 12 or more credit hours, in an institution of higher learning *
If yes, please provide an acceptance letter and class schedule.

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8) Does anyone on the composition pay daycare expenses for child(ren) living in the home that are not reimbursed*
9) Does the composition have educational and/or work-related travel expenses that exceed 60 miles per day? (Doesn't apply to positions where they are based on the number of miles they travel)*

10) Please list all income sources for all members 18 years of age and older, use additional paper if needed. If the income is due to non-employer wages, leave the "Wages Per Hour" and "Hours Per Week" sections blank and only fill out the "Received Monthly" section with the monthly amount (for TANF, interest, pension, dividends, etc: *

	Name	Source of Income	Source of Income address	Source of Income Phone	Wages per hour	Hours per week	Received Monthly
1
2
3
4
5
6

Please provide copies of at least 30 days' worth of income

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11) Does anyone on the composition own land and/or a house? If so, are you receiving rental income as a result of this property?*
12) Have you ever been convicted of a crime since moving into an NPHA unit? If yes, explain*
It is the tenant's responsibility to notify NPHA immediately of any changes in family composition, income and/or contact information. NPHA requires that all tenants re-certify at least annually, and will mail the tenant re-certification paperwork.

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 of Head of Household*

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Date*

MonthDayYear
Date
Upload any other documents you wish to send us here

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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*
Printed Name*
_XXX-XX- Last 4 digits of social security number*
Other Adult
Printed Name
_XXX-XX- Last 4 digits of social security number
Other Adult
Printed Name
_XXX-XX- Last 4 digits of social security number
Other Adult
Printed Name
_XXX-XX- Last 4 digits of social security number
Should be Empty:

Tenant Re-Certification Form

HOUSEHOLD COMPOSITION

RELEASE OF INFORMATION AUTHORIZATION