HOME REHAB ASSISTANCE PROGRAM

YOU MUST PROVIDE THE FOLLOWING COPIES WITH YOUR APPLICATION: 

• Tribal Enrollment Cards and/or CDIB (for ALL Native American household members)
• Social Security Cards (all household members)
• Birth Certificate (all household members)
• Proof of Property Ownership/Deed
• Any additional information requested by the ASHA (if applicable)

ATTENTION! OUR OFFICE WILL ONLY ACCEPT COMPLETE APPLICATIONS. INCOMPLETE APPLICATIONS WILL BE RETURNED OR FILED INACTIVE. 

PHONE: 405.273.1050 FAX: 405.275.0678                                          WWW.ASHOUSINGAUTHORITY.COM

COMPLETE THE INCOME SECTION IF YOU ARE CURRENTLY A HOMEBUYER PARTICIPANT WITH ASHA

Income Status:

PART A. FAMILY COMPOSITION

OPTIONAL INFORMATION: 

Part B. REHAB ASSISTANCE REQUESTED

Work Assessment: 

An itial inspection will be conducted by the Field Office to determine the level of repairs and priority needs for the home rehab program. 

A pre-meeting will be conducted before any work is performed on your home. You will be given a list of the repairs the Housing Authority is eligible to perform during the meeting. The scope of work is prepared by ASHA and cannot be modified once it is finalized and approved by the Executive Director.

NOTE: The home assessment performed does not guarantee eligibility for the home rehab program. 

Part C. RELEASE OF INFORMATION, PUBLIC DISCLOSURE, RELEASE OF INFORMATION

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, living conditions and change of address.

PUBLIC DISCLOSURE STATEMENT

Section 1000.30 and 1000.32 of the Native American Housing Assistance and Self-Determination Act (NAHASDA) of 1996, mandates that a public disclosure regarding conflicts of interest must be made for selected applicants who 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 of the ASHA, BOC member or elected Tribal Official.

To ensure that all applicants are treated fairly, a public disclosure will be done before you are permitted to participate in the program.

I/We certify that the information given is true and correct to the best of my knowledge. I/We understand that making any false statements is punishable under federal law. I/We understand that furnishing false statements or information is grounds for denial or termination of the Home Rehab Assistance Program.

The ASHA will visually inspect privately owned homes constructed prior to January 1, 1978, to determine if Lead-Based Paint is present.

If a Lead-Based Paint test is required and the finding is positive, the ASHA is not obligated to eliminate the lead-based paint or provide rehabilitation services.

I acknowledge having read, understood and agreed to the above waiver.

ADDITIONAL 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.

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 Board of Commissioners through the grievance policy and procedure governing housing programs. I/We have read and fully understand the policy and guidelines provided with this application.

I/We fully understand that, although the maximum, individual grant amount under this Program is $15,000.00, I/We are not automatically entitled to receive that amount and will not receive that amount if a smaller grant will address the needs identified in this application and verified upon inspection by the ASHA.

If I/We sell the house within five (5) years following the date of completion of repairs, the grant will be voided and I/We will repay the full amount of the grant at the time of settlement to the ASHA.

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.

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.

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