Karuk Tribe Housing Authority Application & Checklist

Transcription

1 Karuk Tribe Husing Authrity Applicatin & Checklist Please make sure that all infrmatin in this applicatin is accurate. The applicatin must be cmpleted in full and all the attachments must be submitted in rder t prcess yur applicatin. Yu must submit cpies f the fllwing infrmatin: Cpies f Scial Security Cards fr all Husehld members listed in the applicatin. Verificatin f Enrllment in an Indian Tribe: Karuk Tribe Enrllment card, CDIB, r ther Tribe. Verificatin f Incme fr all Husehld members listed and mst recent 2 years f tax returns: Including yur W2s, 1099, etc. Verificatin includes but is nt limited t: 2 Current Emplyment Payrll Stubs, AFDC/TANF award letter, Scial Security/SSI statement, Child Supprt, etc. Verificatin shuld shw current and year-t-date incme. Cpies f Bank Statements fr the last tw mnths: This includes; checking, savings and any ther assets. Backgrund infrmatin: If yu have checked YES t any questins in this sectin, please include cmplete infrmatin regarding any felny cnvictins. Authrizatin fr the Release f Infrmatin/Privacy Act Ntice: Must be signed by all adult members in the husehld. Current r frmer Landlrd s: Name, Address, and Phne Number. Yu will nt be cnsidered fr any f the KTHA prgrams until yur applicatin is cmplete. Preference pints and the date f yur cmpleted applicatin will determine placement in accrdance with the HUD and KTHA requirements. POINT SYSTEM Karuk Tribal Member = 200 pts. Member f anther Tribe = 100 pts. Frmula Service Area = 20 pts. Karuk Elder = 200 pts. Disabled/Handicapped = 50 pts. Karuk Near Elderly (55-61) = 50 pts. Substandard Husing = 20 pts. Karuk Descendant = 50 pts. Withut Permanent Husing = 15 pts. Invluntary Displacement = 30 pts. Rent abve 50% f Incme = 10 pts. Wrking (40 hurs) = 100 pts. Health & Safety = 100 pts. Wrking (20 hurs) = 50 pts. Retired Karuk Elder = 50 pts. Full Time Student = 50 pts. Disabled Veteran = 100 pts. Veteran = 50 pts. CRIMINAL RECORD (Negative pints as listed belw) Sex Offender = Battery/Assault Crimes = Drug Related Charges = 999 pts Felny Cnvictins = 500 pts Criminal Misdemeanrs = Negative Landlrd Reference = 50 pts Previusly evicted tenants are nt eligible fr re-admissin fr twenty fur (24) mnths frm the date f evictin. Previus tenants with an utstanding balance are nt eligible fr re-admissin fr sixty (60) days frm the date the balance is paid in full. If an applicant wes mney t the Karuk Tribe r any f its' entities r departments, they will be deemed ineligible fr husing assistance until a payment agreement has been prcessed. Any persns with an utstanding debt t the Karuk Tribe must have a payment agreement that is current befre they will be deemed eligible. Upn receipt f yur at the KTHA ffice, if there is any missing infrmatin yu will be mailed a letter requesting the infrmatin. If yu d nt respnd within furteen (14) days, a secnd letter will be sent requiring a respnse within furteen (14) days. If yu d nt respnd t any f the letters yur applicatin will nt be prcessed. Receipt f negative infrmatin regarding; Credit Histry, Landlrd References and/r Criminal Activity fr any husehld member listed n the applicatin may result in denial f assistance fr any f the KTHA prgrams. It is the applicant s respnsibility t ntify the Karuk Tribe Husing Authrity f any address change. Applicants are urged t cntact the KTHA ffice with questins yu may have regarding any KTHA prgram. SUBMIT YOUR APPLICATION TO: Karuk Tribe Husing Authrity P.O. Bx 1159

2 Happy Camp, CA Phne: (530) Karuk Tribe Husing Authrity Please check the KTHA prgram(s) that yu are applying fr: Lw-Incme Rental Prgram Temprary Rental Prgram Elder/Emergency Vucher Prgram Lease Purchase Prgram Elders Hmes (Cntact KTHA fr Pint Criteria) First-time Hmebuyer Lan Prgram Dwn Payment Assistance Rehabilitatin & Weatherizatin Hme Imprvement Grant/Lan Prgram Hme Replacement Grant Area f Preference: ( ) Yreka ( ) Happy Camp ( ) Orleans Applicant Infrmatin C-Applicant Infrmatin Full Name Full Name Scial Security # Hme Phne Scial Security # Hme Phne Date f Birth Age Date f Birth Age Present Street Address Hw Lng? Present Street Address Hw Lng? Mailing Address Mailing Address City State Zip City State Zip If yu have been at yur current residence fr less than 2 years, please prvide previus landlrd infrmatin. Previus Address Dates - Frm/T Previus Address Dates - Frm/T City State Zip City State Zip Emplyment Infrmatin (List emplyer infrmatin fr a minimum tw years) Name and Address f Emplyer Dates - Frm / T Name and Address f Emplyer Dates - Frm / T Mnthly Incme Mnthly Incme Psitin Held Business Phne Psitin Held Business Phne Name and Address f Emplyer Dates - Frm / T Name and Address f Emplyer Dates - Frm / T Mnthly Incme Mnthly Incme Psitin Held Business Phne Psitin Held Business Phne Name and Address f Emplyer Dates - Frm / T Name and Address f Emplyer Dates - Frm / T Mnthly Incme Mnthly Incme Psitin Held Business Phne Psitin Held Business Phne

3 Karuk Tribe Husing Authrity Husehld Member Infrmatin Please print. List Head f Husehld first and list all persns wh will be living in yur hme. Tribal Full Legal Name Date f Birth Sex Relatinship Scial Security # Rll # Indian Verificatin Qualifying Husehld Member: Tribal Affiliatin: Enrllment Number: Other Verificatin: Incme Infrmatin List all mney earned r received by everyne in the husehld including: Wages, Self-Emplyment, AFDC/TANF, Child Supprt, Scial Security, Disability, Wrkman's Cmp., Retirement/Veterans benefits, Interest & Dividends, alimny,.etc. Husehld Member Surce f Incme Grss Mnthly Amunt Verificatin f incme fr the items listed abve must be attached per the Applicatin Checklist. Liability Infrmatin List all liabilities (excluding yur rent) such as car payments, creditrs, utstanding debts, etc. Husehld Member Debt Paid T Mnthly Payment Amunt If mre space is needed, attach n a separate sheet.

4 Karuk Tribe Husing Authrity Checking / Savings Accunts Checking/ Savings Name(s) n Accunt Bank Accunt # Balance D yu r any husehld member have any ther assets such as stcks, bnds, annuities, etc.? If yes, attach cpies f mst recent statement. Asset Infrmatin Yes N 1 Des any husehld member wn any real estate, bats and/r mbile hme? Yes N 2 Has any husehld member sld, given away, r dispsed f any real estate in the last tw (2) years? Yes N 3 Des anyne utside yur husehld pay any f yur bills? If yes, please explain n back f this sheet. Yes N 4 Please list the autmbiles / mtrcycles that yu wn: Year Make Mdel Year Make Mdel Year Make Mdel Prperty Infrmatin fr Hmewners If anyne in the husehld currently wns prperty, please fill in the fllwing infrmatin Address f Prperty Type f Prperty Date Acquired Present Market Value Amunt Owed Mnthly Payment Current Rental Situatin 5 Are yu living in substandard husing? If yes, please explain n the back f this sheet. Yes N 6 Are yu paying rent in excess f 50% f yur incme? Yes N 7 Are yu being Invluntarily Displaced? If yes, please explain n the back f this sheet. Yes N Disabled / Handicapped Status 8 Is any husehld member Disabled r Handicapped? If yes, please attach dcumentatin. Yes N

5 D yu: Own Rent Share Other: Landlrd Name Karuk Tribe Husing Authrity Cnditin f Current Living Unit Number at current residence: Number f Bedrms: Mnthly Rent: Type f Husehld: Single Family Duplex Apart ment Address City State Zip Mbile/Mfg. Hme Phne Please list husehld items that are in need f repair r items that are inadequate: Backgrund Infrmatin 9 List any ther names used (including Maiden Names): Has any husehld member lived in lw-incme husing? 10 Yes N If yes, list address/dates n the back f this sheet. Has any husehld member been evicted frm a residence? 11 Yes N If yes, explain n back f this sheet. Has any husehld member been cnvicted f a crime? 12 Yes N If yes, explain n the back f this sheet. Des any husehld member have any utstanding debts 13 Yes N wed t KTHA, KT r any f its tribal prgrams? Failure t prvide requested infrmatin may result in delay r denial f applicatin. Declaratins f Applicant and C-Applicant Yes answers shuld be explained n the back f this sheet. Applicant C-Applicant Yes N Yes N a Are there any utstanding judgments against yu? b Have yu declared bankruptcy within the past 7 years? c Have yu ever had prperty freclsed r repssessed? d Are yu a party t a lawsuit? e Are yu presently delinquent r in default n any Federal debt r any ther lan, mrtgage r lan guarantee? f Are yu bligated t pay alimny, child supprt r separate maintenance? g Are yu a c-maker r endrser n any nte? The undersigned specifically acknwledges and agrees that all infrmatin in this applicatin is true and accurate. I/We understand that all changes in incme r husehld cmpsitin must be reprted t the Husing Authrity immediately. I/We understand that any intentinal r negligent misrepresentatin f the infrmatin cntained in this applicatin may result in civil liability and/r prsecutin. The Husing Authrity may verify any infrmatin cntained in this applicatin thrugh any surces, including credit reprting agencies, backgrund checks, criminal investigatins r any ther frm f written r electrnic media. Signature - Head f Husehld Signature - Spuse Date Date Signature - Other Member f Husehld ver 18 Date April-14