• IMPORTANT! Please read this entire document thoroughly and make sure you understand all information before answering questions and applying signatures. Call us with any questions or concerns. All signatures applied will affirm that the information provided is true and exact and that you and the entire household agree with the information contained.

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  • WARNING!

    Any false or misleading information may result in a fine, imprisonment and/or rejection of your application.
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  • **Attention! If enrolled tribe is left blank or you did not attach a CDIB/Tribal Enrollment Card,  the person will not be listed as Native American 

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  • 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.

    We must have a telephone number and address for the landlord(s). (You may attach/upload additional sheets if necessary)
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  • ***Displaced-This category includes only those households displaced by governmental action, or whose dwelling has been extensively damaged or destroyed by extreme weather, fire or other involuntary act. Persons displaced by reasons of misconduct or failure to meet financial obligations are specifically excluded from priority consideration under this category.

  • Rental:
    Elderly rental units are located in Shawnee.
    Family rental units are located in Shawnee, Tecumseh, Earlsboro, Mcloud, and Wanette.
    List below the area of preference in which you would like to live:
    1. 2. 3.      

  • Lease With Option to Purchase:
    List below the area of preference in which you would like to live:
    1. 2. 3.      

  • List Two (2) Personal References:

    Provide COMPLETE mailing addresses and they MUST NOT be related.
  • List Two (2) Next of Kin:

  • INCOME INFORMATION

    Head of Household:
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  • Employment History

    Please list your employment for the past Five (5) years. List present job first. (you may upload a list of additional Employers if necessary)
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  • Spouse/Other Adult Household Member 18 & Older

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

    Please list your employment for the past Five (5) years. List present job first (upload list of additional employers if necessary)
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  • Other Adult Member 18 & Older:

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

    Please list your employment for the past Five (5) years, present job first (upload list of additional employers if necessary)
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  • *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.

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  • 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.
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  • 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: 

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  • This person is considered a potential Conflict of Interest for the following reason:

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  • PLEASE READ NOTICE ABOVE FROM U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT, OFFICE OF INSPECTOR GENERAL AND SIGN BELOW:

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  • 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:
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  • 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.
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  • 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.

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  • For more information, please visit our website

    For more information, please visit our website

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