MORTGAGE ASSISTANCE PROGRAM

MORTGAGE ASSISTANCE PROGRAM
FOR ENROLLED ABSENTEE SHAWNEE TRIBAL MEMBERS
THE ABSENTEE SHAWNEE HOUSING AUTHORITY ONLY ACCEPT COMPLETE APPLICATIONS INCOMPLETE APPLICATIONS WILL BE RETURNED OR FILED INACTIVE
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)Pre-qualification letter to confirm you are working with a lenderAny other documentation requested by the Absentee Shawnee Housing Authority
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MORTGAGE ASSISTANCE PROGRAM APPLICATION
1. Head of Household:

First NameMiddle InitialLast Name
Yes*No
*Include a copy of your tribal enrollment card
YesNo
4. Street Address or P.O. Box #:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
5. Telephone Number home:
Format: (000) 000-0000.
Yes*No
*If yes, please explain:
Part A. Family Composition
List all person(s) living in the household on a permanent basis.

Part A. Family Composition List all person(s) living in the household on a permanent basis.

Rows	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
Part B. Lender Information
Company Name:
Address:
Phone:
Format: (000) 000-0000.
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*You must include a copy of your pre-qualification letter.
Part C. 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):

Clear
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.
YesNo
If, yes please list their names and their relationship to you.
Applicant's Signature

Clear
Date:

MonthDayYear
Date
Applicant's Spouse (if applicable):

Clear
Date:

MonthDayYear
Date
ABSENTEE SHAWNEE HOUSING AUTHORITY OFFICIAL CERTIFICATION
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ABSENTEE SHAWNEE HOUSING AUTHORITY
ACKNOWLEDGEMENTS
Read these certifications carefully before you sign and date your application. Sign in ink.
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 $15,000.
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 amount due according to the grant schedule at the time of settlement to the TDHE.
Applicant's Signature:

Clear
Date:

MonthDayYear
Date
Spouse's Signature (if applicable):

Clear
Date:

MonthDayYear
Date
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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:

Clear
Spouse's Signature (if applicable):

Clear
Date:

Clear
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:

Clear
Spouse's Signature (if applicable):

Clear
Date:

Clear
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.
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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 Employment, Income, and Assets Residences and Rental Activity
Medical or Child Care Allowances Credit and Criminal 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 Past and Present Employers Veterans Administration
Public Housing Agencies) 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.
Head of Household Signature:

Clear
Head of Household Printed Name:
Date:

MonthDayYear
Date
Spouse Signature:

Clear
Spouse Printed Name:
Date:

MonthDayYear
Date
1. Adult Member 18 & Older Signature:

Clear
1. Adult Member 18 & Older Printed Name:
Date:

MonthDayYear
Date
2. Adult Member 18 & Older Signature:

Clear
2. Adult Member 18 & Older Printed:
Date:

MonthDayYear
Date
3. Adult Member 18 & Older Signature:

Clear
3. Adult Member 18 & Older Printed:
Date:

MonthDayYear
Date
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.
Should be Empty:

MORTGAGE ASSISTANCE PROGRAM

FOR ENROLLED ABSENTEE SHAWNEE TRIBAL MEMBERS

MORTGAGE ASSISTANCE PROGRAM APPLICATION

Part A. Family Composition

Part B. Lender Information

Part C. Release of Information, Public Disclosure and Signature

PUBLIC DISCLOSURE STATEMENT

ABSENTEE SHAWNEE HOUSING AUTHORITY OFFICIAL CERTIFICATION

ABSENTEE SHAWNEE HOUSING AUTHORITY

ACKNOWLEDGEMENTS

Privacy Act Statement

Authorization For Release of Information