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 

INCOME STATUS:

If yes, please list household member name and type of assistance:

ADDITIONAL INFORMATION:

LANDLORD HISTORY:

List current and previous landlord information for the past five (5) years.

Part B. Tiny Home Site Information 

An initial site inspection will be conducted by Absentee Shawnee Housing Authority inspector to assess the property to prepare a report whether the property is suitable for the Tiny Home Purchase Program. 

NOTE: By being placed on the waiting list, until this has been done, you are not guaranteed that you have been selected to participate in the Tiny Home Program.

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.

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. 

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. 

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. 

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.

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 

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.

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.

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 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].