AVCPRHA Housing Application Package

AVCPRHA Housing Application Package
YOUR APPLICATION IS INCOMPLETE WITHOUT THE FOLLOWING DOCUMENTS
AND MAY CAUSE A DELAY IN CERTIFYING AND DETERMINING ELIGIBLITY:
1. Copy of your most recent federal income tax return
2. For Seasonal or Self-Employment, the last 3 years taxes and Schedule C’s
3. For SS Benefits, a copy of your benefit letter from Social Security Administration
4. Not completely filling out and signing the application
5. Copy of CIB, Tribal Enrollment ID or Certification by the Tribe

General Information
New HomeRehabilitation
Name*

First NameLast Name
Social Security Number*
Physical Address*

PO BOX Address

Street Address

CityState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
I am an enrolled tribal member of:*
I need assistance in the Village of:

Before you start you will need the following:
- Your most recent tax 1040 information for all ADULTS in the household or a written statement (signed & dated) if you didn't file.
- For Seasonal or Self-Employment, the last 3 years Schedule C tax forms.
- For SS Benefits, a copy of your benefit letter from Social Security Administration.
Family Composition: You must list all persons who would live with you if you were to receive assistance. Failure to do so may result in not accepting your application or termination of you subsidy. (Add a line for each Family Member)
Family Composition Information*
Anticipated Changes in Family Composition:
Income Information: List the details of the income each person in your household receives. Include wages, public assistance, social security, SSI, disability compensation, unemployment, interest, babysitting, child support, annuities, dividends, income from property, grants, Alaska National Guard or Armed Forces Reserves, and self-employment. Please provide proof of income (copies of wage statements, fishing settlements or other paperwork documenting Social Security, SSI, Child Support, etc.).

Source of Income: (Name of Employer, Public Assistance, Social Security, etc.)

Rate: (Hourly, Bi-Weekly, Monthly, etc.)

Type of Income: (Employment Income, Disability Income, Retirement Income, Self-Income, Alimony)
Income Information*
Attach W-2s, proof of income, wage statements, fishing settlements, or other paperwork (social security, SSI, Child Support)

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Asset Information: List the assets of all family members, including checking accounts, savings accounts, IRA’s, CD’s, real estate, stocks, bonds, recreational vehicles and their value, fishing boats and permits. Please provide documentation
Bank Information (Add a Line for Each Family Member)*
Attach any Asset Documentation such as Bank Statements, IRAs, CD's, Stocks, Bonds, etc. (see above)

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Other Assets: Please add the total sum of other assets you currently have.
Other Assets*
YesNo
If yes, describe:
Creditor Information
I have had credit with the following creditors and authorize them to provide credit information to the AVCP Regional Housing Authority for consideration regarding my application for Housing Rehabilitation.
Creditor List

Child Care Information
YesNo
If yes, Amount: $/per (hr/day/wk/mo/yr)
Name of Child Care Provider

First NameLast Name
Phone Number of Child Care Provider
Please enter a valid phone number.Format: (000) 000-0000.
Address of Child Care Provider

PO BOX Address

Street Address

CityState

Zip Code
YesNo
If yes, from where:

Medical Expenses
MedicareMedicaid
YesNo
YesNo
YesNo
If yes, Amount:
Please attach any supporting documents regarding your medical expenses.

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Credit & Landlord References
I have had credit with the following creditors and authorize them to provide credit information to the AVCP Regional Housing Authority for consideration regarding my application for Mutual Help/Low RentHousing. (Add a Row for Each)

Before you sign the Declaration

You could also use the following link to open the Declaration: https://na4.docusign.net/Member/PowerFormSigning.aspx?PowerFormId=73b1946d-2dfd-456f-802f-d99429827e54&env=na4&acct=0173f205-bc77-4003-a8cc-29323dde9f0e&v=2
YesNo
If you are having trouble with the release of information agreement on your device, you have the following options:

You can click on this link Declaration to be redirected to the signature page to sign the Declaration.
Contact us at (907) 543-3121
We could also mail you directly if needed. Make sure your mail address is up to date.
YesNo
If you believe that you have been discriminated against, you may call The Office of Fair Housing and Equal Opportunity at 1-800-669-9777.

Before you sign the Release of Information
You can use the provided link to sign the Release of Information:

Link: Release of Information URL
YesNo
If you are having trouble with the release of information agreement on your device, you have the following options:
1. You can click on this link ROI URL to be redirected to the signature page to sign the ROI.
2. Contact us at (907) 543-3121
3. We could also mail you directly if needed. Make sure your mail address is up to date.
YesNo

Before you sign the Declaration of Eligibility Status
You can use the provided link to sign the Declaration of Eligibility Declaration of Eligibility
YesNo
If you are having trouble with the Declaration of Eligibility on your device, you have the following options:
1. You can click on this link ROI URL to be redirected to the signature page to sign the ROI.
2. Contact us at (907) 543-3121
3. We could also mail you directly if needed. Make sure your mail address is up to date.
YesNo
Should be Empty:

AVCPRHA Housing Application Package

General Information

Housing Assistance

Child Care Information

Medical Expenses

Program Information

Credit & Landlord References