COLLEGE HOUSING ASSISTANCE PROGRAM APPLICATION

COLLEGE HOUSING ASSISTANCE PROGRAM APPLICATION
**DEADLINE FOR FALL SEMESTER IS 60 DAYS PRIOR TO THE FIRST DAY OF CLASS**

**DEADLINE FOR SPRING SEMESTER IS 60 DAYS PRIOR TO THE FIRST DAY OF CLASS**
Name, Head of Household*
Tribal Affiliation*
Street Address or PO Box#*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Work Phone:
Please enter a valid phone number.
Message Phone:
Please enter a valid phone number.
Email Address:
example@example.com
YOUR APPLICATION MUST INCLUDE THE FOLLOWING ITEMS:
- Driver's license or state I.D., for all adult household members
- Tribal Enrollment I.D., for all household members (if applicable)
- Social Security Card, for all household members
- Birth Certificate, for all household members
- Marriage License/Divorce Decree, if applicable
- Previous Year Federal Tax Return, including parents if applicable
- Proof of College Enrollment
- Class Schedule for Upcoming Semester
- Landlord/Rental Agreement
- Any other applicable records, as requested or listed on the Absentee Shawnee Housing Authority website
Upload the required documentation here:

Cancelof
Have you ever participated in any ASHA housing program?*

YesNo
If yes, please explain
Part A. Family Composition

List all person(s) living in the household on a permanent basis (including applicant) below:

*Social Security number is required for all family members who are 6 years of age or older.

	Name	Relationship to Applicant	Date of Birth	Social Security#
1 (Applicant)
2
3
4
5
6
7
8

Are you an enrolled member of the Absentee Shawnee Tribe of Oklahoma?*

YesNo

Part B. Family Income

List all person(s) living in the household on a permanent basis (including applicant) below:

1. Income:

	Employer Name & Address	Salary Per Hour	Salary Per Week	Salary Per Year
1
2
3
4

2. Other Income:

	Source (describe):	Amount Per Month	Amount Per Year
TANF
Social Security
S.S.I.
Unemployment
Pensions
Leases
Own Business
Other:

*Other sources of income include per capita, alimony, relief, service allotments, assistance from relatives, payments for foster children, and any other regular source of income. Please do not list income that cannot be anticipated with certainty.

Do you have an immediate family tie to any of the above-mentioned individuals?*

YesNo
If, yes please list their names and their relationship to you.
I understand that this application is not a contract and is not binding in any manner. I hereby authorize the ASHA to obtain any and all information necessary for the purpose of verifying the statements made above. I also understand that it is my responsibility to inform the ASHA if there is any change in my family status along with reporting any changes in income, full-time student status and change of address.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date

ACKNOWLEDGEMENTS

Read these certifications carefully before you sign and date your application.
I/We certify that all of the answers given are true, complete and correct to the best of my/our knowledge and belief, and that they are made in good faith. This certification is made with the knowledge that the information will be used to determine eligibility to receive financial assistance, and that false or misleading statements may constitute a violation of tribal and federal law and grounds for denial of the assistance being requested.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date
I/We fully understand that submission of an application does not guarantee receipt of assistance, and that resources will be allocated or withheld according to availability of funds, the characteristics and living environments of other applicants and other valid considerations. I/We understand the right to appeal any adverse decision regarding this request for assistance to the BOC through the Grievance Policy. I/We have read and fully understand the policy and guidelines provided with this application.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date
I/We fully understand that, although the maximum, individual grant amount under this Program is $300.00. I/We are not automatically entitled to receive that amount and will not receive that amount if a smaller grant will enable my household to occupy the Dwelling Unit in accordance with the Policy.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date
I/We understand that execution of the agreement is deemed consent to amend it to conform to any provision of NAHASDA and the rules, regulations and policies of the ASHA and/or Tribe. I/We consent to the civil jurisdiction of the District Court of the Absentee Shawnee Tribe of Oklahoma and/or to such jurisdictional court as the ASHA may recognize for purposes of enforcing this Policy.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date

I/We understand that the ASHA shall not be liable for any damage to person or property caused by any action, omission or negligence of the ASHA or any of its employees or agents. Further, I/We agree to hold the ASHA harmless from any claim, obligation, liability, loss, damage or expense, including without limitation attorney's fees and court costs, arising from implementation of the Program.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date
Privacy Act Statement
Part 256 of 25 CFR, established under the mechanism of the Snyder Act, 25 USC 13, provides for the collection of this information. The primary use of this information is by an officer or employee of the Federal or Tribal housing office to determine eligibility for a grant for services provided under HUD and BIA-assisted programs. Additional disclosures of the information may be to a HUD or BIA employee in the conduct of a program review or audit, or to a Federal Law enforcement agency when the agency becomes aware of a violation or possible violation of civil or criminal law. Furnishing the information on this form is required to establish eligibility for your participation in the program.

Authorization for Release of Information
I, the undersigned, herby authorize and direct any agencies, offices, groups, organizations, businesses, or individuals to furnish information concerning myself and/or my household to the Absentee Shawnee Housing Authority ("ASHA"), its duly authorized representative and/or its contracted agent for purposes of verifying my eligibility to receive benefits from ASHA.

Those that may be asked to release the information include, but are not limited to: background screening agencies, the U.S. Social Security Administration, the U.S. Department of Veterans Affairs, the United States Postal Service, medical professionals and facilities, current and previous employers, childcare providers, unemployment and employment agencies, banks and other financial institutions. social service and welfare agencies, support and alimony providers, retirement systems, informal support providers, credit providers and credit bureaus, court and law enforcement agencies, current and previous landlords, public housing agencies, utility companies, schools and colleges, and scholarship providers.

I, understand that, depending on program policies and requirements, verifications and inquiries that may be requested include but are not limited to: identity, employment, marital status, household composition, medical or health issues, income, assets, debts, credit history, criminal history and legal issues, rental history, school enrollment verification and/or transcripts, Federal benefits, State benefits and local benefits.

I, understand I have a right to review any information received in accordance with my release, and have a right to correct any information that I can prove is incorrect.

I acknowledge that a photocopy or facsimile copy of this authorization may be deemed the equivalent of the original and may be used as a duplicate original.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate 15 months from this date signed.

I understand that if I, or any other adult household member, fail to sign this authorization, or revoke this authorization prior to completion of necessary verifications and inquiries, it may constitute grounds for denial or termination of assistance or tenancy, or both.
Applicant Signature*

Clear
Applicant Printed Name*
Date*

MonthDayYear
Date
Adult Household Member Signature

Clear
Printed Name
Date

MonthDayYear
Date
Adult Household Member Signature

Clear
Printed Name
Date

MonthDayYear
Date
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COLLEGE HOUSING ASSISTANCE PROGRAM APPLICATION

Part A. Family Composition

Part B. Family Income

ACKNOWLEDGEMENTS

Privacy Act Statement

Authorization for Release of Information

For more information, please visit our website