Tiny Home Lease Purchase Program

P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
TINY HOME LEASE PURCHASE PROGRAM
Please submit only a COMPLETE application with the following attached documentation for all household members, if applicable:
- Photo I.D.
- Tribal Identification Card
- Social Security Card
- State Birth Certificate
- Marriage License/Divorce Decree
- Declaration 214 Form MUST submit for all household members
- Income Award Letters (SSI, Disability, Unemployment, Workman's Comp., etc)
- Deed or Proof of Ownership to Property
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Income Requirements

Family Size Maximum

1	$54,768
2	$62,592
3	$70,416
4	$78,240

P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
Part C. RELEASE OF INFORMATION, PUBLIC DISCLOSURE

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 DISCLUSURE 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.
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/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.
Signature*

Clear
Date*

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Spouse's Signature (if applicable)

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P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
ADDITIONAL ACKNOWLEGEMENTS

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 for the program, and that false or misleading statements may constitute a violation of tribal and federal law.
Applicant's Signature:*

Clear
Date:*

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Spouse's Signature (if applicable):

Clear
Date:

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I/We fully understand that submission of an application does not gurantee receipt of program eligibility. I/We understand the right to appeal any adverse decision regarding this application for the program 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.
Applicant's Signature:*

Clear
Date:*

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Spouse's Signature (if applicable):

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Date:

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If I/We sell the house within (15) years following the date of lease agreement execution, the lease will be voided and I/We will repay the full amount due according to the loan amount.
Applicant's Signature:*

Clear
Date:*

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Spouse's Signature (if applicable):

Clear
Date:

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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:*

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Spouse's Signature (if applicable):

Clear
Date:

MonthDayYear
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P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
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.

P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
U.S. Department of Housing and Urban Development Office of Inspector General

PLEASE READ & SIGN
Head of Household:*

Clear
Printed/Typed Name*
Date:*

MonthDayYear
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Spouse (if applicable):

Clear
Printed/Typed Name
Date:

MonthDayYear
Date
1. Other Adult Member:

Clear
Printed/Typed Name
Date:

MonthDayYear
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2. Other Adult Member:

Clear
Printed/Typed Name
Date:

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3. Other Adult Member:

Clear
Printed/Typed Name
Date:

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Things You Should Know

Don't risk your chances for federally assisted housing provided by false, incomplete, or inaccurate information on your application forms.
Purpose

This is to inform you that there is certain information you must provide when applying for assisted housing. There are penalties that apply if you knowingly omit information or give false information
Penalties for Committing Fraud

The United States Department of Housing and Urban Development (HUD) places a high priority on
preventing fraud. If your application or recertification forms contain false or incomplete information, you
may be:

• Evicted from your apartment or house:
• Required to repay all overpaid rental assistance you received:
• Fined up to S 10,000:
• Imprisoned for up to 5 years; and/or
• Prohibited from receiving future assistance.

Your State and local governments may have other laws and penalties as well.
Asking Questions

When you meet with the person who is to fill out your application, you should know what is expected of you. If you do not understand something, ask for clarification. That person can answer your question or find out what the answer is.
Completing The Application

When you answer application questions, you must include the following information:

Income

• All sources of money you or any member of your household receives (wages. Welfare payments, alimony,
social security, pension, etc.):
• Any money you receive on behalf of your children (child support, social security for children, etc.);
• Income from assets (interest from a savings account, credit union, or certificate of deposit: dividends from
stock, etc.);
• Earnings from second job or part time job;
• Any anticipated income (such as a bonus or pay raise you expect to receive)

P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
Assets

• All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc. that is owned by you and any adult member of your family's household who will be living with you.
• Any business or asset you sold in the last 2 years for less than its full value, such as your home to your children.
• The names of all of the people (adults and children) who will actually be living with you, whether or not they are related to you.
Signing the Application

• Do not sign any form unless you have read it, understand it, and are sure everything is complete and accurate.
• When you sign the application and certification forms, you are claiming that they are complete to the best of your knowledge and belief. You are committing fraud if you sign a form knowing that it contains false or misleading information.
• Information you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the income you report with various Federal, State, or private agencies to verify that it is correct.
Recertification

You must provide updated information at least once a year. Some programs require that you report any
changes in income or family/household composition immediately. Be sure to ask when you must recertify.

You must report on recertification forms:

• All income changes, such as increases of pay and/or benefits, change or loss of job and/or benefits, etc.,
for all household members.
• Any move in or out of a household member; and,
• All assets that you or your household members own and any assets that was sold in the last 2 years for less than its full value.

Beware of Fraud

You should be aware of the following fraud schemes:

• Do not pay any money to file an application;
• Do not pay any money to move up on the waiting list;
• Do not pay for anything not covered by your lease;
• Get a receipt for any money you pay; and,
• Get a written explanation if you are required to pay for anything other than rent
(Such as maintenance charges).
Reporting Abuse

If you are aware of anyone who has falsified an application, or if anyone tries to persuade you to make false statements, report them to the manager of your complex or your PHA. If that is not possible, then call the local HUD office or the HUD Office of Inspector General (OIG) Hotline at (800) 347-3735. You can also write to: HUD-OIG HOTLINE, (GFI) 451 Seventh Street, S.W., Washington, DC. 20410.

P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
AUTHORIZATION

For Release of Information
CONSENT: I authorize and direct any Federal, State. or local agency. organization. business. or individual to release to Absentee Shawnee Housing Authority any information or materials needed to complete and verify my application for participation, and/or to maintain my continued assistance under the Section 8. Rental Rehabilitation, Low-Income Public and Indian Housing, and/or other housing assistance programs. I understand and agree that this authorization or the information obtained with its use may be given to and used by the Department of Housing and Urban Development (HUD) in administering and enforcing program rules and policies.

INFORMATION COVERED: I understand that, depending on program policies and requirements, previous or current information regarding me or my household may be needed. Verifications and inquiries that may be requested include but are not limited to:

Identity and Marital Status

Medical or Child Care Allowances

Employment, Income, and Assets

Credit and Criminal Activity

Residences and Rental Activity

I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for and continued participation in a housing assistance program.

GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups or individuals that may be asked to release the above information (depending on program requirements) include, but are not limited to:

Previous Landlords (including Public Housing Agencies)

Past and Present Employers

Veterans Administration

Welfare Agencies

Retirement Systems

Courts and Post Offices

State Unemployment Agencies

Banks and other Financial Institutions

Schools and Colleges

Social Security Administration

Credit providers and Credit Bureaus

Law Enforcement Agencies

Medical and Child Care Providers

Utility Companies

Support and Alimony Providers

COMPUTER MATCHING NOTICE AND CONSENT: I understand and agree that HUD or the Public Housing Authority may
conduct computer matching programs to verify the information supplied for my application or recertification. If a computer match is done, I understand that I have a right to notification of any adverse information found and a chance to disprove that information. HUD may in the course of its duties exchange such automated information with other Federal, State, or local agencies, including but not limited to: State Employment Security Agencies; Department of Defense; Office of Personnel Management; the U.S. Postal Service; the Social Security Agency; and State welfare and food stamp agencies.

CONDITIONS: I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in affect for a year and one month from the date signed.
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.

P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
FEDERAL PRIVACY ACT NOTICE

Section 8 Rental Certificate, Rental Voucher, Moderate Rehabilitation, and Public and Indian Housing Program.
PURPOSE:

Family income and other information is being collected by the Department of Housing and Urban Development (HUD) to determine an applicant’s eligibility, the recommended unit, size, and the amount the family must pay toward rent and utilities.

USE:

HUD uses family income and other information to assist in managing and monitoring HUD-assisted housing
programs, to protect the Government’s financial interest, and to verify the accuracy of the information furnished. HUD or a public housing agency/Indian housing authority may conduct a computer match to verify the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal or regulator investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law.

PENALTY:

You must provide all information requested by the public housing agency/Indian housing authority including all social security numbers you and all other household members age six (6) years and older, have and use. Giving the social security numbers of all household members 6 years of age and older is mandatory, and not providing the social security numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

AUTHORITY FOR INFORMATION COLLECTION:

The following laws authorize the collection of the information by HUD or the public housing agency/Indian housing authority; the U.S. Housing Act of 1937 (42 U.S.C. 1437 et seq.), Title VI of the Civil Rights Acts of 1964, and Title VIII of the Civil Rights Act of 1968. The Housing and Community Development Act of 1987 (42 U.S.C. 3443) requires applicants and residents to submit the social security numbers of all household members at least six (6) years old.
I read the Federal Privacy Act Notice on*

MonthDayYear
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Signature Head of Household:*

Clear
Signature Spouse or Other Adult (if applicable)

Clear

P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
DECLARATION OF SECTION 214 STATUS

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, blanks certify, under penalty of perjury, that to the best of my knowledge, I am lawfully within the United States because (Please check appropriate box):
Type a question*

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 proof of age. iiI have eligible immigration status as checked below (see reverse side of this form for explanations). AttachINS document(s) evidencing eligible immigration status and signed verification consent form.Immigration status under §§ 101 (a)(15) or 101(a)(20) of the Immigration and Nationality Act (INA) iii.Permanent residence under § 249 of the INA ivRefugee, asylum or conditional entry status under §§ 207, 208 or 203 of the INA vParole status under § 212 (d)(5) of the INA viThreat to life or freedom under §§ 243 (h) of the INA viiAmnesty under § A of the INA viii
Signature*

Clear
Date*

MonthDayYear
Date

P.O. Box 425 107 N. Kimberly Ave. Shawnee, OK 74802-0425

Phone (405) 273-1050 Fax (405) 273-0678 Website: www.ashousingauthority.com
i Warning: 18 U.S.C. 100t provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statements or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than five years, or both.

The following footnotes pertain to non-citizens who declare eligible immigration status in one of the following categories:

ii Eligible immigration status and 62 years of age or older. For noncitizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, 1995. If you are eligible and elect to select this category, you must include a documents providing evidence of proof of age. No further documentation of eligible immigration status is required.

iii Immigrant status under § 101(a)(15) or 101(a)(20) of the INA. A noncitizen lawfully admitted for permanent residence, as defined by § 101(a)(20) of the immigration and nationality Act (INA), as an immigrant, as defined by § 101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101 (a)(15), respectively [immigrant status]. This category includes a noncitizen admitted under § 210 or 210A of the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has been granted lawful temporary resident status.

iv Permanent residence under § 249 of the INA. A noncitizen who entered the U.S. before January 1, 1972, or such later date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is not eligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under § 249 of the INA (8 U.S.C. 1259) [amnesty granted under INA 249 ]

v Refugee, asylum, or conditional entry status under §§ 207,208 or 203 of the INA. A noncitizen who is lawfully present in the U.S. pursuant to an admission under § 207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under § 208 of the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under § 203(a)(7) of the INA (U.S.C.1153(a)(7)) before April 1, 1980 because of persecution or fear of persecution on account of race, religion or political opinion or because of being uprooted by catastrophic national calamity [conditional entry status].

vi Parole status under § 212(d)(5) of the INA. A non-citizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under § 212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status].

vii Threat to life or freedom under § 243(h) of the INA. A noncitizen who is lawfully in the U.S. as a result of the Attorney General's withholding deportation under § 243(h) of the INA (8 U.S.C. 1253(h)) [Threat to life or freedom].

viii Amnesty under § 245A of the INA. A noncitizen who is lawfully admitted for temporary or permanent residence under § 245A of the INA (8 U.S.C. 1255a) [Amnesty granted under INA 245A].
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TINY HOME LEASE PURCHASE PROGRAM

TINY HOME PURCHASE PROGRAM

Part A. Family Composition

Part C. RELEASE OF INFORMATION, PUBLIC DISCLOSURE

PUBLIC DISCLUSURE STATEMENT

Privacy Act Statement

U.S. Department of Housing and Urban Development Office of Inspector General

Things You Should Know

FEDERAL PRIVACY ACT NOTICE