NAHASDA Housing Assistance Application

NAHASDA Housing Assistance Application
Eligibility for NAHASDA(Must meet all criteria):
- Resident of the western two-thirds of Shasta County or those in Trinity County
- Enrolled member of a federally recognized Native American Tribe
- Household income that meets the HUD income guidelines
Application Submission:

Redding Rancheria Tribal Office

2000 Redding Rancheria Rd , CA 96001

Deadline: 1st April 2024

For questions or need information, please contact

Coleen Wilkes, Community Services Coordinator

Phone: 530-242-4538, Fax: 530-241-1879

Email: Coleen.Wilkes@reddingrancheria-nsn.gov
Applicant Information
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*
Please enter a valid phone number.
Home Phone Number
Please enter a valid phone number.
Email*
example@example.com
Tribal Affiliation *
Please upload necessary documents (tribal affiliation, state ID, etc.,)*

Cancelof
Required documents : Please select all that apply*

Completed application (all questions must be answered, all members of the household must be added and all income listed.)Tribal Enrollment CardState or Government Issued ID for all adults 18 years and olderCopies of Social Security cards for all family membersOne month of income verification for household (include all sources of income. If any source of income changes from month-to-month you must provide the last 3 months of income verification for that source.)Full copy of rental/lease or mortgage payment agreements (if applicable)Recent utility bill or business mail (mailing must be dated with applicant's name and address)All adults must provide signatures on pages 10, 11, and 13.
Privacy Act Notice: Any person, who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.00. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek relief, as may be appropriated, against the officer or employee of HUD, Redding Rancheria (RR) or the owner responsible for the unauthorized disclosure or improper use.

Please Note: Is your application complete with all information? It will be rejected upon later after review if all required documents/information are not submitted with application.
Are you renting?*

YesNo
Is your home overcrowded?*

YesNo
Does your home have heat?*

YesNo
Does your home have water?*

YesNo
Does your home have electricity?*

YesNo
Does your home have sewer?*

YesNo
Head of Household
First Name *
Last Name *
Middle Initial
Nickname
Place of Birth
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Message

YesNo
Sex
Date of Birth
Social Security Number
Tribal Affiliation*
Enrollment Number*
Veteran

YesNo
Currently in military

YesNo
Branch of service
Full time student

YesNo
School Name and Address
Marital Status
Handicapped/Disabled?

YesNo
If handicapped/disabled check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Employer Phone Number
Please enter a valid phone number.
Welfare Information:
Case Number
Case Worker
Phone Number
Please enter a valid phone number.
Child Support Information:
Case Number
Case Worker
Phone Number
Please enter a valid phone number.
References: List names, addresses and phone numbers of 3 people (not relatives) who you have known for at least 5 years. References might include employers or former employers, teachers, clergy, your family doctor or your landlord.
Reference One:
Reference Two:
Reference Three:
Spouse or Co-Tenant
First Name
Last Name
Middle Initial
Nickname
Place of Birth
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Message

YesNo
Sex
Date of Birth
Social Security Number
Tribal Affiliation
Enrollment Number
Veteran

YesNo
Currently in military?

YesNo
Branch of service
Full Time Student?

YesNo
School Name and Address
Handicapped/Disabled?

YesNo
If Handicapped/disabled, check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Head of Household
Additional Household Members
List number of additional household members in the family. *
Household Member One
First Name*
Last Name*
Middle Initial
Nickname
Place of Birth
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Message

YesNo
Sex
Social Security Number
Date of Birth
Tribal Affiliation
Enrollment Number
Veteran

YesNo
Currently in military?

YesNo
Branch of service
Full Time Student?

YesNo
School Name and Address
Handicapped/Disabled?

YesNo
If handicapped/disabled, check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Head of Household
Household Member Two
First Name*
Last Name*
Middle Initial
Nickname
Place of Birth
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Message

YesNo
Sex
Date of Birth
Tribal Affiliation
Social Security Number
Enrollment Number
Veteran

YesNo
Currently in military?

YesNo
Branch of Service
Full Time Student?

YesNo
School Name and Address
Handicapped/Disabled?*

YesNo
If handicapped/disabled, check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Head of Household
Household Member Three
First Name*
Last Name*
Middle Initial
Nickname
Place of Birth
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Message

YesNo
Sex
Date of Birth
Tribal Affiliation
Social Security Number
Enrollment Number
Veteran

YesNo
Currently in military?

YesNo
Branch of service
Full Time Student?

YesNo
School Name and Address
Handicapped/Disabled?

YesNoOther
If handicapped/disabled, check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Head of Household
Household Member Four
First Name*
Last Name*
Middle Initial
Nickname
Place of Birth
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Message

YesNo
Sex
Date of Birth*
Social Security Number
Tribal Affiliation
Enrollment Number
Veteran

YesNo
Currently in military?

YesNo
Branch of service
Full Time Student?

YesNo
School Name and Address
Handicapped/Disabled?

YesNo
If handicapped/disabled, check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Head of Household
Household Member Five
First Name*
Last Name*
Middle Initial
Nickname
Place of Birth
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Message

YesNo
Sex
Date of Birth
Social Security Number
Tribal Affiliation
Enrollment Number
Veteran

YesNo
Currently in military?

YesNo
Branch of service
Full Time Student?

YesNo
School Name and Address
Handicapped/Disabled?

YesNo
If handicapped/disabled, check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Head of Household
Household Member Six
First Name*
Last Name*
Middle Initial
Nickname
Place of Birth
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)
Please enter a valid phone number.
Phone Number (Work)
Please enter a valid phone number.
Message

YesNo
Sex
Date of Birth
Social Security Number
Tribal Affiliation
Enrollment Number
Veteran

YesNo
Currently in military?

YesNo
Branch of service
Full Time Student?

YesNo
School Name and Address
Handicapped/Disabled?

YesNo
If handicapped/disabled, check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Relationship to Head of Household
Household Member Seven
First Name*
Last Name*
Middle Initial
Nickname
Place of Birth*
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number (Home)*
Please enter a valid phone number.
Phone Number (Work)*
Please enter a valid phone number.
Message*

YesNo
Sex*
Date of Birth*
Social Security Number *
Tribal Affiliation*
Enrollment Number
Veteran*

YesNo
Currently in military?*

YesNo
Branch of service
Full Time Student?*

YesNo
School Name and Address
Handicapped/Disabled?*

YesNo
If handicapped/disabled, check all that apply

DevelopmentalMentalPhysicalHearingVisualWheelchair
Occupation
Employer
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Relationship to Head of Household*
If separated or divorced, list name and address of your spouse (or ex-spouse)
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Social Security Number
Income Information
List the details of the income each person in your household receives. Include wages, public assistance, social security, SSI, disability compensation, CalFresh, unemployment, interest, babysitting, child support, annuities, dividends, income from property, grants, National Guard or Armed Forces Reserves and self-employment. Please provide proof of income (copies of check stubs, wage statements, settlements or other paperwork documenting Social Security, SSI, child support, etc.)

IF ANY SOURCE OF INCOME IN THE HOUSEHOLD CHANGES FROM MONTH-TO-MONTH PLEASE PROVIDE THE LAST THREE MONTHS OF INCOME VERIFICATION (STUBS) FOR THAT SOURCE OF INCOME.

Income Information of Family Members

	Family Member Name	Income Source	Total Amount of an average check	How many paydays per month?
1.
2.
3.
4.
5.
6.
7.

Please provide further details on income source(s) in the household that may be abnormal (paydays, seasonal employment, etc.,) This will allow for an easier, less time consuming calculation of annual income. *
Asset Information

List the assets of all family members, including checking accounts, savings accounts, IRAs, CDs, real estate, stocks, bonds, recreational vehicles and their value, fishing boats and permits.
Please provide documentation*

Cancelof
Checking Account:
Bank
Address
Account Number
Balance
Savings Account:
Bank
Address
Account Number
Balance
Credit Union Shares:
Bank
Address
Account Number
Balance
Other Assests:
Stocks & Bonds (Value)
War Bonds (Value)
IRA/CD's (Value)
Real Estate (Value)
Recreational Vehicles (Value)
Other (Value)
Other (Value)
Other (Value)
Have you sold any real estate in the last two years? If yes, describe
Child Care Expenses
Child care expense*

YesNo
If yes, mention $amount per (hour/day/week/month/year)
For example: $20 per hour
Name and Address of Child Care Provider
Phone Number
Please enter a valid phone number.
Do you receive day care assistance?

YesNo
If yes, mention Assistance %
Medical Expenses
Are you receiving Medicare Benefits?

YesNo
Are you receiving Medicare Assistance from Public Assistance?

YesNo
Do you pay for doctor's services, for medical insurance or hospitalization? (Blue Cross, Aetna etc.,)

YesNo
If yes, mention $amount per hour
For example: $40 per hour
Do you pay for prescription drugs?

YesNo
If yes, mention $amount per hour
For example: $40 per hour
Program Information
Have you or has any member of your family applied for or participated in a rental assistance program, including Redding Rancheria NAHASDA?

YesNo
If yes, where and under what name?
Does anyone outside of your household pay for any of your bills or give you money?

YesNo
If yes please explain?
Have you or has any other adult members of your household ever used any name(s) other than the names listed on this application?

YesNo
If yes please explain?
Have you or has any other adult member of your household ever used any social security number(s) other than the social security number(s) listed on this application?

YesNo
If yes please explain?
Have you or has anyone in your household ever been convicted of a crime other than a traffic violation? Has your record been expunged of criminal charges and/or completion of Drug Program requirements/ please submit with application. certificate of completion and/or dates of completion.

YesNo
If yes please explain?
Credit, Mortgage and Landlord References

I have had credit with the following creditors, and authorize them to provide credit information to the Redding Rancheria for consideration regarding my application for NAHASDA assistance.
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Account Number
Phone Number
Please enter a valid phone number.
Fax Number
Declaration:
- I (We) certify that the information provided in this application is accurate and complete to the best of my (our) knowledge and belief.
- I (We) understand that providing false statements or information is punishable under Federal Law and constitutes grounds for termination of housing assistance.
- I (We) further certify that I (We) do not owe any money to any Indian Housing Authorities or Housing Departments.
- All household members, including applicant, agree not to engage in any illegal activity, including but not limited to violent crimes, sexual crimes, and manufacturing of unlawful substances.
Date

MonthDayYear
Date
Signature of Head of Household

Clear
Date

MonthDayYear
Date
Signature of Spouse/Co-Tenant

Clear
Date

MonthDayYear
Date
Signature of Adult Household Member(18 year or older)

Clear
Date

MonthDayYear
Date
Signature of Adult Household Member(18 year or older)

Clear
Date

MonthDayYear
Date
Signature of Adult Household Member(18 year or older)

Clear
Date

MonthDayYear
Date
Signature of Adult Household Member(18 year or older)

Clear
Authorization for the Release of Income Information
Consent: I consent to allow HUD and/or the Redding Rancheria to request and obtain information from the sources listed in this application for the purpose of verifying my eligibility and level of benefits under Redding Rancheria and HUD’s assisted housing programs. I understand that information received under this consent form cannot be used to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest such determinations.

This consent expires 12 months after it is signed.
Date

MonthDayYear
Date
Signature of Head of Household

Clear
Date

MonthDayYear
Date
Signature of Spouse/Co-Tenant

Clear
Date

MonthDayYear
Date
Signature of Adult Household Member(18 year or older)

Clear
Date

MonthDayYear
Date
Signature of Adult Household Member(18 year or older)

Clear
Date

MonthDayYear
Date
Signature of Adult Household Member(18 year or older)

Clear
Date

MonthDayYear
Date
Signature of Adult Household Member(18 year or older)

Clear
Privacy Act Notice Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the Native American Housing Assistance and Self-Determination Act of 1996 (PL104-330), Title VI of the Civil Rights Act of 1964 (42U.S.C.2000d), and by the Fair Housing Act (42U.S.C.3601-19). The Housing and Community Development Act of 1987 (42U.S.C.3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD and the Redding Rancheria (RR) to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your 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 you provide. This information may be released to appropriate Federal, State and local agencies, when relevant, and to civil, criminal, or regulatory 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 the information requested by the Redding Rancheria, including all Social Security Numbers you and all other household members six 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.

Penalties for Misusing this Consent: HUD, RR and any owner (or any employee of HUD, RR or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on this consent form. Use of the information collected based on the form HUD9886 is restricted to the purposes cited on the form HUD9886. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek relief, as may be appropriated, against the officer or employee of HUD, RR or the owner responsible for the unauthorized disclosure or improper use.

Original is retained by the requesting organization. ref. Handbooks 7420.7, 7420.8 & 74465.1
Elderly (over age 62), Handicapped or Disabled: Consent for Release of Information to Social Security Administration
NOTE: The information below only needs to be filled by house members that are Elderly (over 62), Handicapped or Disabled.
Name

First NameLast Name
Date of Birth
Social Security Number
I authorize the Social Security Administration to release information or records about me to: Redding Rancheria, 2000 Redding Rancheria Rd, Redding, CA 96001.

I want this information released to the above named organization to verify my income. I am either an applicant for admission as a tenant to the federally aided housing unit operated by the organization, or a tenant having an annual recertification. The Redding Rancheria will use the information to determine my eligibility status and the amount of my rent.

(There may be a charge for releasing information).
Please release the following information

Gross Monthly Social Security Benefit Amount, Type of Benefit, and Date of BirthGross Monthly Supplemental Security Income Payment Amount (Including State Supplement),Type of Benefit, and Date of Birth.
Signature

Clear
Date

MonthDayYear
Date
Relationship
Authorization for the Release of Information
Organizations Requesting release of information (Name, Address, Telephone and Date) :

Redding Rancheria Housing Department

2000 Redding Rancheria Rd.

Redding, CA 96001

(530) 225-8979 FAX (530) 242-4560

Purpose: The above named organization may use this authorization and the information obtained with it, to administer and enforce program rules and policies.

Authorization: I authorize the release of any information (including documentation and other materials) pertinent to eligibility for or participation under any of the following programs.

              Rental Assistance Program (RAP)

              Emergency Rental Assistance (ERAP)

              Temporary Assistance Program (TAP)

              Emergency Mortgage Assistance (MAP)

I authorize the above named organization to obtain information about me or my family that is pertinent to eligibility for or participation in assisted housing programs.

I authorize only the Redding Rancheria Housing Department to obtain information on wages or unemployment compensation from State Employment Securities Agencies.

Information Covered: Inquiries may be made about:

              Per Capita / Revenue Sharing

              Child Care Expenses

              Credit History

              Criminal Activity

              Family Compensation

              Employment, Income, Pensions, and Assets

              Federal, State, Tribal or Local Benefits

              Handicapped Assistance Expenses

              Identity and Marital Status

              Social Security Numbers

Residences and Rental History

Individuals or Organizations that May Release Information: Any individual or organization including any Governmental organization may be asked to release information. For example:

              Tribes, Alaskan Villages or Corporations

              Banks and other Financial Institutions

              Law Enforcement Agencies / Courts

              Credit Bureau

              Employers (past and present)

              Landlords

              Providers of:

                              Alimony

                              Child Care

                              Child Support

                              Handicapped Assistance

                              Medical Care

                              Pensions / Annuities

              Schools and Colleges

              U.S. Social Security Administration

              U.S. Department of Veterans Affairs

              Utility Companies

              Welfare Agencies

Computer Matching Notice & Consent: I agree that the Redding Rancheria Housing Department may conduct computer matching programs with other governmental agencies including Federal, State, Tribal or local agencies. The governmental agencies include:

              U.S. Office of Personnel Management

              U.S. Social Security Administration

              U.S. Department of Defense

              State Employment Security Agencies

              State Welfare and Food Stamp Agencies

That match will be used to verify information supplied by the family.

Conditions: I agree that photocopies of this authorization may be used for the purposes stated above. If do not sign this authorization, I also understand that my housing assistance may be denied or terminated.
Printed Name of the Head of Household & Date
Signature of Head of Household

Clear
Printed Name of Spouse or Co-Tenant & Date
Signature of Spouse or Co-Tenant & Date

Clear
Printed Name of Other Adult Member of the Household & Date
Signature of Other Adult Member of the Household & Date

Clear
Printed Name of Other Adult Member of the Household & Date
Signature of Other Adult Member of the Household & Date

Clear
Declaration of 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 U.S. Please read the Declaration statement below carefully, and sign and return to the Redding Rancheria. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing if you desire.
I, _______ , certify, under penalty of perjury1, that to the best of my knowledge I am lawfully within the United States because:
Print Name
Check all that apply

I am a citizen by birth, a naturalized citizen or a national of the United States; orI have eligible immigration status and I am 62 years of age or older (Attach evidence of proof of age)2; orI have eligible immigrationstatus as checked below. Attach INS documents evidencing eligible immigration status and signed verification consent formImmigrant status under 101(a)(15) or 101(a)(20) of the Immigration and Nationality Act (INA)3; orPermanent residence under 249 of INA4; orRefuge, asylum, or conditional entry status under 207, 208 or 203 of the INA5; orParole status under 212(d)(5) of INA6; orThreat to life or freedom under 243(h) of INA7; orAmnesty under 245A of INA8.
Date

MonthDayYear
Date
Signature

Clear
1. Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing and false, fictitious, or fraudulent statement 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 noncitizens who declare eligible immigration status in one of the following categories:

2. 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 section 214 covered program on June 19, 1995. If you are eligible and elect to select this category, you must include a document providing evidence of proof of age. No further documentation of eligible immigration status is required.

3. Immigrant status under §§101(a)(15) or 101(a)(20) of 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.

4. Permanent residence under §249 of 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 ineligible for citizenship, but who is deemed to be lawfully admitted for permanent 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].

5. Refugee, asylum, or conditional entry status under §§207, 208 or 203 of 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].

6. Parole status under §212(d)(5) of INA. A noncitizen 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].

7. Threat to life or freedom under §243(h) of INA. A noncitizen who is lawfully present 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].

8. Amnesty under §245A of INA. A noncitizen lawfully admitted for temporary or permanent residence under §245A of the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A].

Instructions to Housing Authority: Following verification of status claimed by persons declaring eligible immigration status (other than noncitizens age 62 or older and receiving assistance on June 19, 1995), HA must enter INS/SAVE Verification Number and date that it was obtained. A HA signature is not required.

Instructions To Family Member For Completing Form: On opposite page, print or type first name, middle initial(s), and last name. Place an “X” or “ü” in the appropriate boxes. Sign and date at bottom of page. Place an “X” or “ü” in the box below the signature if the signature is by the adult residing in the unit who is responsible for Child.
Housing Questionnaire
Have you received assistance from this program before?

YesNo
Has your home been tested for hazardous lead through NAHASDA?

YesNo
Is housing established?

YesNo
If no, what are your current living arrangements?
If housing is established, what is your monthly rent?
If you are chosen to receive assistance from this program will you looking to find a (new) home to rent?

YesNo
If yes, is there anything you feel may hold you back from being approved for housing through a property management company?
Additional comments or suggestions to improve this program?
IMPORTANT INFORMATION: Incomplete applications will not be accepted. THERE WILL BE NO EXCEPTIONS.

If you need copies from your file, have questions or need assistance with this application please call prior to the day you plan to submit your application.

You must inform the Redding Rancheria of any change in address or telephone number.

Applicant must be an enrolled member of a federally recognized tribe.

Faxed applications will be denied.

You do not need to provide a rental agreement if you do not currently rent a property and you plan to apply for assistance to find new housing. Once housing is established, you will have to provide an agreement.

Types of assistance you can apply for:

Rental Assistance: Monetary assistance with a rental deposit, one full month of rent and three half-rental payments.

Temporary Assistance: For families that find themselves in emergency situations due to unforeseen events. Circumstances must be verifiable through documentation.

Coleen Wilkes

Community Services Coordinator

2000 Redding Rancheria Road Redding, CA 96001

Phone # (530) 242-4538

Email: Coleen.Wilkes@reddingrancheria-nsn.gov
Should be Empty:

NAHASDA Housing Assistance Application

Applicant Information

Head of Household

Spouse or Co-Tenant

Additional Household Members

Household Member One

Household Member Two

Household Member Three

Household Member Four

Household Member Five

Household Member Six

Household Member Seven

If separated or divorced, list name and address of your spouse (or ex-spouse)

Income Information

Asset Information

Child Care Expenses

Medical Expenses

Program Information

Credit, Mortgage and Landlord References

Authorization for the Release of Income Information

Elderly (over age 62), Handicapped or Disabled: Consent for Release of Information to Social Security Administration

Authorization for the Release of Information

Housing Questionnaire