Over Income Down Payment Assistance Program

Absentee Shawnee Housing Authority

Over-Income Down Payment Assistance Program
THE ABSENTEE SHAWNEE HOUSING AUTHORITY ONLY ACCEPT COMPLETE APPLICATIONS INCOMPLETE APPLICATIONS WILL BE RETURNED OR FILED INACTIVE
You must attach all of the following documents with the application in order for the application to be processed:
- Photo Identification for all household members over the age of 18.
- CDIB and /or Tribal Enrollment Cards (for ALL Native American household members)
- Social Security Cards (all household members)
- State Birth Certificates (all household members)
- Marriage License/Divorce Decree/Custody Decree (if applicable)
- Award Letters for Income (Social Security, SSI, Disability, Unemployment Benefits and Workman's Comp, etc. ) if applicable
- Copies of paycheck stubs from the Applicant and each household member with earned income
- Federal Tax Returns filed for the previous year and current year (if filed)
- Copies of 2 months of the most recent paycheck stubs (all household members)
- Certified Statements from any household member who is self-employed
- Copy of Sales Contract (if applicable)
Any other documentation requested by the Absentee Shawnee Housing Authority
Email*
example@example.com
Upload Files Here (Refer to required document checklist above)*

See required document checklist above
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Upload Copy of Sales Contract (if applicable)

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OVER INCOME DOWN PAYMENT ASSISTANCE APPLICATION
Head of Household*
The assistance is for enrolled member of the Absentee Shawnee Tribe. Provide your Roll # *
Elderly/Handicapped?*

YesNo
Street Address or P.O. Box #*
City*
State*
Zip*
Home Telephone Number
Work Telephone Number
Message Telephone Number *
Have you ever participated in Absentee Shawnee housing program(s)?*

YesNo
If yes, please explain
Have you ever participated in other Tribal housing program(s)?*

YesNo
If yes, please explain
List all person(s) living in the household on a permanent basis.

Part A. Family Composition

	Name	Relationship	Date of Birth	Social Security #
1.
2.
3.
4.
5.
6.
7.
8.

*Social Security number is required for all family members who are 6 years of age or older
B. Are you an enrolled member of the Absentee Shawnee Tribe?

YesNo

Part B. Family Income

	Complete Employer Name(s)&Address	Per Hour	Per Week	Per Year
1.
2.
3.
4.

2. Other Income

	Per Month	Per Year
TANF
Social Security
S.S.I
Unemployment
Pensions.
Leases.
Own Business.
Other*

*Other sources of income include 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.
C. Total family income for next 12 months:$ blanks
D. Please attach copies of the most recent IRS 1040 forms that were filed for the prior year and most recent pay stubs for all applicable members of the family.
Attach Files Here

Cancelof

Part D. Release of Information, Public Disclosure and Signature

I understand that this application is not a contract and is not binding in any manner. I hereby authorize the Absentee Shawnee Housing Authority to obtain any and all information necessary for the purpose of verifying the statements made above. I approve the Housing Authority to pull my credit report for the review of my application. I also understand that it is my responsibility to inform the Absentee Shawnee Housing Authority if there is any change in my family status along with reporting any changes in income, living conditions and change of address.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Applicant's Spouse (if applicable)
Date

MonthDayYear
Date
PUBLIC DISCLOSURE STATEMENT

The Absentee Shawnee Housing Authority policies mandate that a public disclosure regarding conflicts of interest must be made on individuals who apply for assistance from the Absentee Shawnee Housing Authority 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 officer of the Absentee Shawnee Housing Authority elected Tribal Official or Executive Committee Member.

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.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Applicant's Spouse (if applicable)
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 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*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date
I/We fully understand the maximum, individual amount of assistance under this Program is $5,000.
Applicant's Signature*

Clear
Date*

MonthDayYear
Date
Spouse's Signature (if applicable)

Clear
Date

MonthDayYear
Date

If I/We sell the house within the Binding Commitment Agreement years following the date the assistance was rendered, the subsidy will be voided and I/We will repay the full amount of the grant at the time of settlement to the TDHE.
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 the rules, regulations and policies of the Absentee Shawnee Housing Authority 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 Housing Authority 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 TDHE shall not be liable for any damage to person or property caused by any action, omission or negligence of the TDHE or any of its employees or agents. Further, I/We agree to hold the TDHE 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.

Absentee Shawnee Housing Authority

107 N. Kimberly

Shawnee, OK 74801

AUTHORIZATION FOR RELEASE OF INFORMATION

This release of information constitutes my consent and authorization to the the agencies or representatives identified to furnish ABSENTEE SHAWNEE HOUSING AUTHORITY MAXIMUM REPORTS, INC., and/or its representative's permission and authority to conduct a credit check in order to determine my suitability for Down Payment Assistance Program with ABSENTEE SHAWNEE HOUSING AUTHORITY. I understand and consent to an investigation that is limited to criminal and civil record history information, motor vehicle driving history, human services inquiry for domestic violence, child abuse or neglect information, employement verification, educational verification, professional licensing, personal and professional rederences and credit reports whether or not such information would otherwise be protected from disclosure by any constitutional, statutory or common law priveldge.

I authorize the custodians of such records and sources of information to release the information, including permittting the review and copying of all documents, records or correspondence pertaining to me, to the representatives of ABSENTEE SHAWNEEE HOUSING AUTHORITY and MAXIMUM REPORTS,INC., regardless of any previous agreement to the contrary.

I agree to accept all risks of adverse public notice, embarrassment, criticism or financial loss that may result from use of information that is obtained in connection with a background investigation for the purpose listed in this document.

I agree to indemnify and hold harmless any person to whom this is lawfully presented and his agent and employees from and against all claims, damages, losses, and expenses, including reasonable attorney's fees, arising out or by reason of complying with this request.
Applicant's Full Name (please print) *
Social Security Number*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth*
Driver's License Number
State *
Signature*

Clear
Date*
Should be Empty:

Absentee Shawnee Housing Authority

OVER INCOME DOWN PAYMENT ASSISTANCE APPLICATION