Application for Housing

Name

Mailing Address

City/State/Zip

Phone

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

There are no Entries.

Maximum number of entries reached.

Do you expect the number of household members to change in the future:

Yes

If YES, please explain

Current Housing Status and Need:

1) Current Living Arrangements

2) Renting/Leasing:

Yes

Monthly Amount:

How long renting:

“Landlord Verification Form” MUST be completed

3) Housing Status:

Substandard Conditions

Displacement as of

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

There are no Entries.

Maximum number of entries reached.

Zero Income Verification:

Are YOU or is ANY OTHER ADULT member of your household claiming zero income?

Yes

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

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

Household Member

Bank or Financial Institution

Amount

2.) Trust Funds?

Yes/No

Yes

Household Member

Bank or Financial Institution

Amount

3.) Pension, IRA, 401(k) or other retirement account?

Yes/No

Yes

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 NPHA 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 Only

Date 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 reason

Date

MM slash DD slash YYYY