OVER INCOME LEASE TO OWN PROGRAM

OVER INCOME LEASE TO OWN PROGRAM
Please upload all documentation as listed above:

Cancelof

APPLICANT INFORMATION
Name*

First NameMiddle NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own or rent?*
Monthly house payment?*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Phone Number*
Please enter a valid phone number.
Email
example@example.com
Rental History for the past *5 years (list most recent first)

*List any additional Landlord history on separate sheet of paper and upload with other requested documents.
1. Landlord Name*
Landlord Phone Number*
Please enter a valid phone number.
Landlord Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Rental Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Length of Occupancy?*
2. Landlord Name
Landlord Phone Number
Please enter a valid phone number.
Landlord Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Rental Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lenght of Occupancy?
3. Landlord Name
Landlord Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Landlord Phone Number
Please enter a valid phone number.
Rental Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lenght of Occupancy?
Employment Information
Current Employer*
Employer Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Start Date*

MonthDayYear
Date
End Date

MonthDayYear
Date
The above is my current employer (check box)

Yes
Annual Income $*
Position*
If you have been with your current employer less than *3 years, list below previous employment:

*List any additional employment on a separate sheet of paper and upload with other requested documents.
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Annual Income $
Position
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Start Date

MonthDayYear
Date
End Date

MonthDayYear
Date
Annual Income $
Position

Spouse &/Or Other Adult Information
Name

First NameMiddle InitialLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
DOB
SSN
Phone
Spouse &/or Other Adult employment information:
Employer
Employer Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone
Hire date

MonthDayYear
Date
Annual Income $
Position
Household Composition

List all household members below (Applicant First):

	Name	Relationship to applicant	Sex	Date of Birth	Social Security #
1.Applicant:
2.
3.
4.
5.
6.

References

List 3 personal references below. (Must not be related)
Name*
Relation*
How long have you known this person?*
Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip
Phone*
Name*
Relation*
How long have you known this person?*
Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip
Phone*
Name*
Relation*
How long have you known this person?*
Mailing Address*

Mailing Address

Street Address Line 2

CityState

Zip
Phone*
Emergency Contact
Name*
Phone*
Relation*
Acknowledgement
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 understand I am subject to a home visit, credit report check, and criminal background to provide any additional information necessary to complete the application process.

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 the Housing Authority send me and I understand that failure to do so will result In the application becoming Inactive.
Signature of Applicant*

Clear
Date*

MonthDayYear
Date
Signature of Spouse &/or Other Adult

Clear
Date

MonthDayYear
Date

PUBLIC DISCLOSURE STATEMENT
A public disclosure regarding conflicts of interest must be made on individuals who apply for assistance from the ASHA and have immediate family ties (mother, father, husband, wife, daughter, son, brother, sister, mother-in-law, father-in-law, daughter-in-law, son-in-law) to any employee or board member of the ASHA or elected Tribal Official.

To ensure that all applicants are treated fairly, a public disclosure will be made before you are permitted to participate in the program.
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.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date

AUTHORIZATION FOR RELEASE OF INFORMATION

(All adult household members will need to sign for authorization)
Applicant Signature*

Clear
Printed/Typed Name:*
Date*

MonthDayYear
Date
Spouse Signature

Clear
Printed/Typed Name:
Date

MonthDayYear
Date
Adult Household Member Signature

Clear
Printed/Typed Name:
Date

MonthDayYear
Date
Adult Household Member Signature

Clear
Printed/Typed Name:
Date

MonthDayYear
Date
Adult Household Member Signature

Clear
Printed/Typed Name:
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 jurisdiction.

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 appropriate box):*

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

Immigration status under §§ 101 (a)(15) or 101(a)(20) of the Immigration and Nationality Act (INA)Permanent residence under § 249 of the INARefugee, asylum or conditional entry status under §§ 207, 208 or 203 of the INAParole status under § 212 (d)(5) of the INAThreat to life or freedom under §§ 243 (h) of the INAAmnesty under § 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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OVER INCOME LEASE TO OWN PROGRAM

APPLICANT INFORMATION

Rental History for the past *5 years (list most recent first)

Employment Information

If you have been with your current employer less than *3 years, list below previous employment:

Spouse &/Or Other Adult Information

Household Composition

References

Emergency Contact

Acknowledgement

PUBLIC DISCLOSURE STATEMENT

AUTHORIZATION FOR RELEASE OF INFORMATION

DECLARATION OF SECTION 214 STATUS

For more information, please visit our website