Application for Housing "*" indicates required fields Name* Mailing Address* City/State/Zip* Phone*Email* Tribal Entrollment* Household Information Complete the following information for each household member that occupies the home, include military if they are considered household members, even if they are currently deployed:Household Information Name Relationship to the Head of Household SEX Date of Birth Student Occupation Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Do you expect the number of household members to change in the future: Yes No If YES, please explainHow many bedrooms?*2 bedrooms3 bedrooms4 bedrooms5 bedroomsCurrent Housing Status and Need:1) Current Living Arrangements* 2) Renting/Leasing:* Yes No Monthly Amount:* How long renting: “Landlord Verification Form” MUST be completed3) Housing Status:* Substandard Conditions Displacement as of Other Income Information: Earned income is counted only for household members 18 or older.Unearned income such as a grant or benefit is counted for all household members, including minors. Include all GROSS income (before taxes) each household member expects to earn in the next 12 months.Check One* Weekly Bi-Weekly Semi-Monthly Monthly Income Information Name Rate of Pay Source of Income, Phone & Address Estimated Income Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Zero Income Verification:Are YOU or is ANY OTHER ADULT member of your household claiming zero income?* Yes No If YES, who? and “Certification of Zero Income Form” MUST be completed.Have you, your spouse/co-applicant ever filed or are currently filing for bankruptcy?* Yes No Asset Information: Include all assets and the corresponding annual interest rate, dividends or any other income derived from the asset. An asset is defined as any lump sum amount that you hold in your name and currently have access to.Include the value of the asset and corresponding income from the asset in the space provided.1.) Checking or savings account?Yes/No* Yes No Household Member* Bank or Financial Institution* Amount* 2.) Trust Funds?Yes/No Yes No Household Member* Bank or Financial Institution* Amount* 3.) Pension, IRA, 401(k) or other retirement account?Yes/No Yes No Household Member* Bank or Financial Institution* Amount* Signature Clause: I certify that all information and answers to the questions are true and complete to the best of my knowledge. I consent to release the necessary information to determine my eligibility for housing occupancy. I understand that providing false information or making false statements may be grounds for denial of my application. I also understand that such action may result in criminal penalties. I hereby grant San Ildefonso Housing Authority the right to process this application for the purpose of obtaining housing. Additionally, I authorize all corporations, companies, law enforcement agencies, academic institutions, current/former landlords and current/former employers to release information they may have about me and release them from any liability and responsibility from doing so. A photographic or faxed copy of this authorization shall be as valid as the original. I agree that I may have to participate with full cooperation in SIHAs Counseling Program and understand that failure to participate without good cause may result in revocation of selection or termination of this application. I understand that this IS NOT a contract and does not bind either party. I understand that in compliance with the FAIR CREDIT REPORTING ACT the processing of this application includes but is not limited to making inquires deemed necessary to verify the accuracy of the information I provided, including procuring consumer reports from the consumer credit reporting agencies and obtaining credit information from other credit institutions. I also understand and agree that SIHA intends to use the credit report the purpose of evaluation my financial readiness and resources available.Consent* I understand that all required forms, supporting documentation*All household members 18 and over must sign below:Signature* Date* MM slash DD slash YYYY Signature* Date* MM slash DD slash YYYY Signature* Date* MM slash DD slash YYYY Signature* Date* MM slash DD slash YYYY For SIHA Office Use OnlyDate Application Received MM slash DD slash YYYY Received By: 1.) Date Checklist & Supporting Docs Complete: MM slash DD slash YYYY Verified By: 2.) Date Income Verification Form Complete: MM slash DD slash YYYY Verified By: 3.) Date Landlord Verification Form Complete: MM slash DD slash YYYY Verified By: 4.) Date Child Care Verification Form Complete: MM slash DD slash YYYY Verified By: 5.) Date Eligible for Waiting List Placement: MM slash DD slash YYYY Entered By: Based on all documentation/verifications received this applicant had been determined to be: ELIGIBLE for Admission INELIGIBLE for Admission Signature of SIHA Authorized Representative: Title: Date: MM slash DD slash YYYY If Ineligible, state reasonDate MM slash DD slash YYYY UntitledFirst ChoiceSecond ChoiceThird ChoiceUntitled First Choice Second Choice Third Choice Untitled First Choice Second Choice Third Choice