PO Box 425 107• N. Kimberly Shawnee, OK 74802-0425
Phone 405-275-1050 • Fax 405-275-0678

The request for addition to household form must be completed for each person you want to add to your household. All required documents must be submitted with the request or your request will not be processed. When an addition to household is submitted the first time will be a courtesy. Thereafter, a $20.00 fee will be charged each additional time.

The following is a list of the documents required to process your request:

1. Completed Addition to Household form
2. Colored copy of Driver's License
3. Social Security Card
4. CDIB
5. State Birth Certificate
6. Release of Information Form
7. Marriage License and/or Divorce Decree
8. Declaration of Section 214 Status (Citizenship)
9. Income Verification Form or Unemployment Statement (over 18)
10. A notarized Affidavit must be completed if you are unemployed and receiving no benefits.

A background check will be required from the OSBI on all persons over the age of 18.

Submission of your request does not guarantee approval. Individuals are not to move into your home until after you receive a letter from the Housing Authority stating your request has been approved.

PO Box 425 107 N. Kimberly Shawnee, OK 74802-0425
Phone 405-275-1050 Fax 405-275-0678

I request approval for the Absentee Shawnee Housing Authority to add the following individual to my household:

Attention! You must attach his/her CDIB and/or Tribal Enrollment Card if you list a Tribal Affiliation. If you leave this blank or do not attach a copy of the card they will not be listed as Native American.

You must attach the following documentation with this packet in order to complete your request: ☐ Social Security Card, ☐ State Birth Certificate.

Don't risk your chances for federally assisted housing by providing false, incomplete, or inaccurate information on your application forms.

Purpose
This is to inform you that there is certain information you must provide when applying for assisted housing. There are penalties that apply if you knowingly omit information or give false information.

Penalties for Committing Fraud
The United States Department of Housing and Urban Development (HUD) places a high priority on preventing fraud. If your application or recertification forms contain false or incomplete information, you may be:

• Evicted from your apartment or house:
• Required to repay all overpaid rental assistance you received:
• Fined up to $10,000:
• Imprisoned for up to 5 years; and/or
• Prohibited from receiving future assistance.

Your state and local governments may have other laws and penalties as well.

Asking Questions
When you meet with the person who is to fill out your application, you should know what is expected of you. If you do not understand something, ask for clarification. That person can answer your question or find out what the answer is.

Completing The Application
When you answer application questions, you must include the following information:

Income

• All sources of money you or any member of your household receives (wages. Welfare payments, alimony, social security, pension, etc.):
• Any money you receive on behalf of your children (child support, social security for children, etc.);
• Income from assets (interest from a savings account, credit union, or certificate of deposit: dividends from stock, etc.);
• Earnings from second job or part time job;
• Any anticipated income (such as a bonus or pay raise you expect to receive)

• All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc. that is owned by you and any adult member of your family's household who will be living with you.
• Any business or asset you sold in the last 2 years for less than its full value, such as your home to your children.
• The names of all of the people (adults and children) who will actually be living with you, whether or not they are related to you.

• Do not sign any form unless you have read it, understand it, and are sure everything is complete and accurate.
• When you sign the application and certification forms, you are claiming that they are complete to the best of your knowledge and belief. You are committing fraud if you sign a form knowing that it contains false or misleading information.
• Information you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the income you report: from various Federal, State, or private agencies to verify that it is correct.

You must provide updated information at least once a year. Some programs require that you report any changes in income or family/household composition immediately. Be sure to ask when you must recertify. You must report on recertification forms:

• All income changes, such as increases of pay and/or benefits, change or loss of job and/or benefits, etc., for all household members.
• Any move in or out of a household member, and,
• All assets that you or your household members own and any assets that was sold in the last 2 years for less than its full value.

You should be aware of the following fraud schemes:

• Do not pay any money to file an application;
• Do not pay any money to move up on the waiting list;
• Do not pay for anything not covered by your lease;
• Get a receipt for any money you pay; and,
• Get a written explanation if you are required to pay for anything other than rent (Such as maintenance charges).

If you are aware of anyone who has falsified an application, or if anyone tries to persuade you to make false statements, report them to the manager of your complex or your PHA. If that is not possible, then call the local HUD office or the HUD Office of Inspector General (OIG) Hotline at (800) 347-3735. You can also write to: HUD-OIG HOTLINE, (GFI) 451 Seventh Street, S.W., Washington, DC. 20410.

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.

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.

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 United States. Please read the Declaration statement carefully and sign. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.

Waming: 18 U.S.C. 100t provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statements 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:

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

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

Permanent residence under § 249 of the 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 eligible for citizenship, but who is deemed to be lawfully admitted for permanent residence 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]

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

Parole status under § 212(d) (5) of the INA. A non-citizen 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].

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

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