HAF Application for Assistance

AVCP Regional Housing Authority Homeowner Assistance Fund Program Application for Assistance

Phone: (907)543-1337

Email: nandrew@avcphousing.org
1. Applicant Information
Type of Assistance Request*

Mortgage DelinquencyMortgage DefaultMortgage ForeclosureLoss of UtilitiesLoss of Home Energy ServiceInternet Service AssistanceHome Insurance AssistanceHOA FeesCondominium Association FeesPrevention of Displacement of HomeownerRehabilitation/ModernizationWeatherization
Name
Address

Mailing Address

Street Address Line 2

Physical AddressState / Province

City, State, Zip
Landline or Cell Phone Number
Please enter a valid phone number.
Email Address
example@example.com
2. Tribal Affiliation
Name of Tribe
Tribe Address

Mailing Address

Street Address Line 2

City, State, ZipState / Province

Postal / Zip Code
Calista Enrollment Number
3. Mortgage Company

If Mortgage Assistance Needed
Mortgage Company
Address

Mailing Address

Street Address Line 2

City. State and ZipState / Province

Postal / Zip Code
Office Landline or Cell
Please enter a valid phone number.
4. Utility Providers Information

If Assistance Needed
Fuel Assistance?

YesNo
Fuel provider

Name

Address

CityState / Province

Telephone
Office number
Please enter a valid phone number.
Stove Oil Receipt/Invoice

Cancelof
Electricity Assistance?

YesNo
Electric Company

Name

Address

CityState / Province

Telephone
Office number
Please enter a valid phone number.
Account Balance/Latest Bill

Cancelof
Water/Sewer Assistance?

YesNo
Water/Sewer Provider

Name

Address

CityState / Province

Telephone
Office number
Please enter a valid phone number.
Account Balance/Latest Bill

Cancelof
Internet Assistance?

YesNo
Internet Provider

Name

Address

CityState / Province

Telephone
Office Number
Please enter a valid phone number.
Account Balance/Latest Bill

Cancelof
5. Family Composition, Income, and Eligible For
1. Head
Full Name
Date of Birth

MonthDayYear
Date
Received PFD?
Yes/No
Filed 2022 Taxes?

YesNo
Other income document

2022 W2IRS Form 1099Last Paystub of 2022Depository Institution StatmentsAttestation from EmployerUnemployedOther
2022 Taxes or Other Income Document

Cancelof
2. Spouse
Full Name
Date of Birth

MonthDayYear
Date
Received PFD?
Yes/No
Filed 2022 Taxes?

YesNo
Other Income Document

2022 W2IRS Form 1099Last Paystub of 2022Depository Institution StatmentAttestation from EmployerUnemployedOther
2022 Taxes or Other Income Document

Cancelof
3.

AdultChild
Name
Full Name
Date of Birth

MonthDayYear
Date
Received PFD?
Yes/No
Filed 2022 Taxes?

YesNo
Other Income Document

2022 W2IRS Form 1099Last Paystub of 2022Depository Institution StatmentAttestation from EmployerUnemployedOther
2022 Taxes or Other Income Document

Cancelof
4.

AdultChild
Name
Full Name
Date of Birth

MonthDayYear
Date
Received PFD?
Yes/No
Filed 2022 Taxes?

YesNo
Other Income Document

2022 W2IRS Form 1099Last Paystub of 2022Depository Institution StatmentAttestation from EmployerUnemployedOther
2022 Taxes or Other Income Document

Cancelof
5.

AdultChild
Name
Full Name
Date of Birth

MonthDayYear
Date
Received PFD?
Yes/No
Filed 2022 Taxes?

YesNo
Other Income Document

2022 W2IRS Form 1099Last Paystub of 2022Depository Institution StatmentAttestation from EmployerUnemployedOther
2022 Taxes or Other Income Document

Cancelof
6.

AdultChild
Name
Full Name
Date of Birth

MonthDayYear
Date
Received PFD?
Yes/No
Filed 2022 Taxes?

YesNo
Other Income Document

2022 W2IRS Form 1099Last Paystub of 2022Depository Institution StatmentAttestation from EmployerUnemployedOther
2022 Taxes or Other Income Document

Cancelof
7.

AdultChild
Name
Full Name
Date of Birth

MonthDayYear
Date
Received PFD?
Yes/No
Filed 2022 Taxes?

YesNo
Other Income Document

2022 W2IRS Form 1099Last Paystub of 2022Depository Institution StatmentAttestation from EmployerUnemployedOther
2022 taxes or Other Income Document

Cancelof
Please give details of financial hardship, and/or Rehabilitation/Modernization/Weatherization request details.
6. Supporting Documents for Qualifier
Check the appropriate box of attached documents

Mortgage DelinquencyMortgage DefaultMortgage ForclosurePrevention of Displacement of HomeownerHomeowner Insurance AssistanceCondominium Association FeesLoss of UtilitiesLoss of Home Energy ServicesInternet Services AssistanceQualified ExpensesWeatherizationRehabilitation/Modernization
7. Other Documents
Check the appropriate box of attached documents

Attestation as to the household income REQUIREDLast paystub of 2022IRS Form 1099Tax ReturnsDepository institution statementsAttestation from employer orOther
I/We certify that the information provided to the AVCP Regional Housing Authority for the Homeowner Assistance Fund Program on household composition, income, and qualifiers are accurate and complete to the best of my/our knowledge and belief. I/We understand false statements or information are punishable under federal law. I/We also understand false statements or information are grounds for termination of the Homeowner Assistance Fund Program*
Full Name
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Date*

MonthDayYear
Date
Spouse
Full Name
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Date

MonthDayYear
Date
ATTESTATION

ATTESTATION. AVCP RHA will require homeowners to attest that they experienced financial hardship after January 21, 2020. The attestation must describe the nature of the financial hardship (for example, job loss, reduction in income, or increased costs due to healthcare or the need to care for a family member).

Financial Hardship means a material reduction in income or material increased in living expenses associated with the coronavirus pandemic that has created or increased a risk of mortgage delinquency, mortgage default, foreclosure, loss of utilities or home energy services, or displacement for a homeowner.
Income - By signing I attest to my household income and attaching supporting documents such as:

INCOME: check this box if providing:PaystubsW2's or other wage statementsIRS Form 1099sTax filingsDeposiory Institude StatementAttestation from an employerNot EmployedDid not complete taxes
Financial Hardship - By signing I attest I have experienced hardship after January 21, 2020. Financial hardship included:

FINANCIAL HARDSHIP: check this box if experienced/experiencing:Material Reduction in incomeMaterial increased in living expenses that has created or increased risk of:Mortgage DelinquencyMortgage defaultForeclosureLoss of utilitiesLoss of home energy servicesDisplacement of homeownerRehabilitatioon/ModernizationWeatherizationArrearages of Qualified ExpensesIncreased healthcare costsCare for family member
Please describe the nature of your Financial Hardship
Rehabilitation/Modernization and/or Weatherization request details:
Please provide details of
Signature - By signing I attest to the income and the financial hardship of my application for the AVCP Regional Housing Authority Homeowner Assistance Fund program*

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Date

MonthDayYear
Date
Should be Empty:

1. Applicant Information

2. Tribal Affiliation

3. Mortgage Company

4. Utility Providers Information

5. Family Composition, Income, and Eligible For

6. Supporting Documents for Qualifier

7. Other Documents