HOUSING APPLICATION RENTAL/HOMEOWNERSHIP

Check box of program in which you are applying for:*

Lease with Option to PurchaseRentalBoth Programs
WARNING!

Any false or misleading information may result in a fine, imprisonment and/or rejection of your application.

Have you ever filed an application with the Absentee Shawnee Housing Authority?
Yes or no?
If yes, when?
Year, Month and date if available
Have you ever filed an application with any other Housing Authority?
Yes or no?
If so, which one?
Name of other HA
When?
Year, date and month if available
Have you ever lived in low rent housing before?
Yes or no?
If so, which one?
Name of Low Rent housing provided
When?
Year, date and month if available
Have you or your spouse ever lived in Mutual Help housing?
Yes or no?
If so, which one?
When?
Year, date and month if available
Have you or any family member been evicted?
Yes or no?
If yes, explain the circumstances:
If so, please list Landlord:
In what year were you evicted?
Have you or any member of your household been arrested?
Yes or no?
If yes, list person's (or persons') name(s)
Crime committed?
Year
County/State
Have you or any member of your household been convicted of a felony?
Yes or no
If yes, list person's (or persons') name(s)
Crime committed?
Year
County/State
*Important Notice*

NO PETS OF ANY KIND ARE ALLOWED IN ANY OF THE RENTAL UNITS
I have answered every question and filled in all the requested information to the best of my ability. No fraudulent statements have been made or implied, and I have no objection to inquiries being made for the purpose of verification of statements made herein. I fully understand that false statements are subject to prosecution and/or rejection of my application. By signing this application, I agree to allow a home visit and also provide any additional information requested. I understand that is my responsibility to update my application at least once a year, and must notify the Absentee Shawnee Housing Authority of any change of address, income or family composition and to answer any correspondence that the Housing Authority sends to me and I understand that failure to do so will result in the application becoming inactive.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse/Other Adult Member 18 & Older Signature (if applicable)

Clear
Date

MonthDayYear
Date
Other Adult Member 18 & Older Signature (if applicable

Clear
Date

MonthDayYear
Date

ABSENTEE SHAWNEE HOUSING AUTHORITY PUBLIC DISCLOSURE NOTICE:

Please list any relationship to Staff, Board of Commissioners, or Council according to the Conflict of Interest Policy on the previous page.
Today's (disclosure) Date*

MonthDayYear
Date
Name of Applicant related:
Name of Staff Member related to (if applicable)
Name of Board Member related to (if applicable)
Name of Council Member related to (if applicable)
Per 24 CFR 1000.30 a public disclosure must be made in accordance with the Absentee Shawnee Housing Authority's Conflict of Interest Policy.

Notification of Potential or Appearance of Conflict of Interest
Per 24 CFR 1000.30 and Absentee Shawnee Housing Authority Conflict of Interest Policy, this is to notify your office that the above named individual will be provided assistance through the Absentee Shawnee Housing Authority program:
Notification Date

MonthDayYear
Date
Name of Applicant related:
Applicant
This person is considered a potential Conflict of Interest for the following reason:
Check any reason below a that could be a potential Conflict of Interest:

Employee of ASHAMember of the ASHA Board of CommissionersMember of the Absentee Shawnee Tribal Council"Immediate" Relative to an ASHA Employee"Immediate" Relative to an ASHA Board Member"Immediate" Relative to an Absentee Shawnee Council Member
Do you have an immediate family tie to any of the above-mentioned individuals?*

YesNo
If yes, Please list their names and relationship to you:
Signature*

Clear
Today's Date*

MonthDayYear
Date

Signature, Head of Household*

Clear
Date*

MonthDayYear
Date
Signature, Adult Member 18 & Older (if applicable)

Clear
Date

MonthDayYear
Date
Signature, Adult Member 18 & Older (if applicable)

Clear
Date

MonthDayYear
Date
Signature, Adult Member 18 & Older (if applicable)

Clear
Date

MonthDayYear
Date

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department of Agency of the U.S. as to any matter within its jurisdiciton.

All household members 18 years or older must sign. Please sign below to authorize release of Information:
Signature (Head of Household)*

Clear
Printed Name (Head of Household)*
Date Signed (Head of Household)*

MonthDayYear
Date
Signature of Spouse (if applicable)

Clear
Printed Name of Spouse (if applicable)
Date Signed by Spouse

MonthDayYear
Date
Signature (other adult household member, 18 or older; if applicable)

Clear
Printed Name of Other Adult Household Member, 18 or older
Date Signed (Other household member, 18 or older)

MonthDayYear
Date
Signature (other adult household member, 18 or older; if applicable)

Clear
Printed Name of Other Adult Household Member, 18 or older
Date Signed (Other household member, 18 or older)

MonthDayYear
Date
Signature (other adult household member, 18 or older; if applicable)

Clear
Printed Name of Other Adult Household Member, 18 or older
Date Signed (Other household member, 18 or older)

MonthDayYear
Date

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD's assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.

This consent form expires 16 months after signed.
Signature, Head of Household*

Clear
Date Signed, Head of Household*

MonthDayYear
Date
Social Security Number, Head of Household*
Signature of spouse (if applicable)

Clear
Date Signed, Spouse

MonthDayYear
Date
Signature, Other family member over age 18 (if applicable)

Clear
Date Signed, Other family member over age 18

MonthDayYear
Date
Signature, Other family member over age 18 (if applicable)

Clear
Date Signed, Other family member over age 18

MonthDayYear
Date
Signature, Other family member over age 18 (if applicable)

Clear
Date Signed, Other family member over age 18

MonthDayYear
Date
Signature, Other family member over age 18 (if applicable)

Clear
Date Signed, Other family member over age 18

MonthDayYear
Date
Signature, Other family member over age 18 (if applicable)

Clear
Date Signed, Other family member over age 18

MonthDayYear
Date
Signature, Other family member over age 18 (if applicable)

Clear
Date Signed, Other family member over age 18

MonthDayYear
Date

I read the Federal Privacy Act Notice on Date:*

MonthDayYear
Date
Signature, Head of Household*

Clear
Signature of Spouse, or Adult Member 18 & Older (if applicable)

Clear
Signature of Adult Member 18 & Older (if applicable)

Clear

Declaration of Section 214 Status

ATTN: FOR HEAD OF HOUSEHOLD'S SIGNATURE ONLY, PLEASE REQUEST ADDITIONAL FORMS FOR ALL OTHER HOUSEHOLD MEMBERS AT OFFICE, OR PRINT FROM PDF FILE ON WEBSITE AND UPLOAD WITH SUPPORTING DOCUMENTS
Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance, must be lawfully within the United States. Please read the Declaration statement carefully and sign. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.
I certify under penalty of perjury, that to the best of my knowledge, I am lawfully within the United States because (please check the appropriate box):*

I am a citizen by birth, a naturalized citizen or a national of the United StatesI have eligible immigration status and I am 62 years of age or older. (Upload proof of age)I have eligible immigration status as checked below (see bottom of this page for explanations). Upload INS document(s) evidencing eligible immigration status and signed verification consent form.
I have eligible immigration status as checked below:

Immigration status under section 101 (a) (15) or 101 (a)(20) of the Immigration and Nationality Act (INA)Permanent Residence under statute 249 of the INARefugee, asylum or conditional entry status under section 207, 208 or 203 of the INAParole status under statute 212 (d)(5) of the INAThreat to life or freedom under section 243 (h) of the INAAmnesty under section A of the INA
Name, Head of Household*
Signature, Head of Household*

Clear
Date Signed:*

MonthDayYear
Date
For more information, please visit our website

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	Name: Last, First, MI	Relation	List Enrolled Tribe**	Sex	Date of Birth (DD/MM/YYYY)	Birth Place	Social Security #
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WARNING!

ATTENTION! YOU MUST UPLOAD COPIES OF THE FOLLOWING ITEMS LISTED BELOW OR THE APPLICATION WILL NOT BE PROCESSED.

Include the following color copies (be sure they are clear and visible).

Any rental history reported to us on a credit report or landlord that deems you or a household member unsuitable will automatically determine you ineligible for housing services.

List Two (2) Personal References:

List Two (2) Next of Kin:

INCOME INFORMATION

Employment History

Spouse/Other Adult Household Member 18 & Older

Employment History (Spouse/Other Adult Member 18 & Older)

Other Adult Member 18 & Older:

Employment History (2nd/Other Adult Member 18 & Older)

Important Notice

ABSENTEE SHAWNEE HOUSING AUTHORITY PUBLIC DISCLOSURE NOTICE:

Per 24 CFR 1000.30 a public disclosure must be made in accordance with the Absentee Shawnee Housing Authority's Conflict of Interest Policy.

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department of Agency of the U.S. as to any matter within its jurisdiciton.

Declaration of Section 214 Status

For more information, please visit our website

	County	City
1
2
3
4

WARNING!

ATTENTION! YOU MUST UPLOAD COPIES OF THE FOLLOWING ITEMS LISTED BELOW OR THE APPLICATION WILL NOT BE PROCESSED.

Include the following color copies (be sure they are clear and visible).

Any rental history reported to us on a credit report or landlord that deems you or a household member unsuitable will automatically determine you ineligible for housing services.

List Two (2) Personal References:

List Two (2) Next of Kin:

INCOME INFORMATION

Employment History

Spouse/Other Adult Household Member 18 & Older

Employment History (Spouse/Other Adult Member 18 & Older)

Other Adult Member 18 & Older:

Employment History (2nd/Other Adult Member 18 & Older)

*Important Notice*

ABSENTEE SHAWNEE HOUSING AUTHORITY PUBLIC DISCLOSURE NOTICE:

Per 24 CFR 1000.30 a public disclosure must be made in accordance with the Absentee Shawnee Housing Authority's Conflict of Interest Policy.

WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any Department of Agency of the U.S. as to any matter within its jurisdiciton.

Declaration of Section 214 Status

For more information, please visit our website

Important Notice