LUKACHUKAI CHAPTER GOVERNMENT #036 HOUSING RENOVATION ASSISTANCE APPLICATION DOCUMENT CHECK LIST

Transcription

1 1 Date: LUKACHUKAI CHAPTER GOVERNMENT #036 HOUSING RENOVATION ASSISTANCE APPLICATION DOCUMENT CHECK LIST NAME: AGENCY: CHINLE CHAPTER: LUKACHUKAI REHABILITATION OTHER (SPECIFY) A. Housing Application (Exhibit A) B. Land Ownership Documents (Copy of Home Site Lease #, Arch., Land Use Permit) C. Social Security Card(s)/Photo I.D. D. C.I.B. (Certificate of Indian Blood) E. Income Verification Statement(s)/ Copy of Check Stubs F. Floor Plan of Sketches with Dimensions (Rehabilitation) G. Materials Requirement Listing for Rehabilitation H. Authorizations for Release of Information (Income Doc.) I. Chapter Voter s Registration (May be Verified by Chapter Administration) Verified By: Name& Title Date J. 3 Vendors Quotation for Material Listing K. Others (Referrals, Recommendations, Etc.)

2 2 LUKACHUKAI CHAPTER GOVERNMENT #036 HOUSING RENOVATION ASSISTANCE APPLICATION I. Applicant Information: Head of Household Census No. Social Security No. Date of Birth Spouse Census No. Social Security No. Date of Birth Mailing Address City State Zip Code Telephone # Marital Status: Married Single Widow(er) Other Name(s) of dependents(s) under the age 18 living with you: II. Are you disabled or handicapped? Present Home Characteristics: Owner: Services connected? Year Built: Type of Construction: Frame Block Adobe Other Type of Condition: Excellent Good Fair Poor Size of Structure: Number of Rooms: Can home be brought to present day standard? Nearest electricity supply: Nearest water supply: Nearest sewer supply:

3 3 III. Employment and/or Income Information A. Head of Household: HOUSING RENOVATION APPLICATION Are you employed? Occupation: Names and addresses of employer: How long were you employed? Rate of Pay: B. Spouse: Are you employed? Occupation: How long were you employed? Rate of Pay: Name of employer: Name and address of granting agency (list all other source of income) C. Dependent(s): If other household members are employees or receiving other sources of income please list the employment and income information: I. Total House Annual Income Calculation (OFFICE USE ONLY) A. Head of Household Income $ B. Spouse Income $ C. Dependent(s) Other Income $ Total Household Family Income $

4 4 HOUSING RENOVATION ASSISTANCE Have you ever received Housing Assistance from the Chapter in the past? If Yes when? Type of Assistance: (Month/Year) From Whom? For what purpose are you requesting assistance from the Lukachukai Chapter Housing Renovation Program? (Please be specific) Comments:.. Date: I (We), the undersigned, hereby certify that the information given above is true and correct to the best of my (our) knowledge and given in good faith for the purpose of applying and obtaining housing renovation assistance from the Lukachukai Chapter. The Housing Renovation Assistance Program may use the said information to obtain information or source documents from other housing providers or housing related granting agencies. I (We) hereby authorize the said information to be used for the above stated purpose. Applicant Signature Spouse Signature

5 5 HOUSING RENOVATION APPLICATION VERIFICATION OF INCOME AND AUTHORIZATION TO RELEASE INFORMATION Sir/Madam: The Lukachukai Chapter is requesting your assistance in verifying income information of the applicant or his/her spouse or dependent applying for housing renovation assistance under our Chapter Assistance Program. To assist our office and our housing applicant, we are asking you to provide us with income information. Any information supplied by your organization be held in strict confidence for official use only I determining eligibility pursuant policies and procedures of the program. Below is a signature authorization for your release of said information and documentation to us. Your sincere cooperation and prompt release of said information to our office will be most appreciated. Date: Respectfully, Committee President Lukachukai Housing Discretionary Committee ***************************************************************************************** I HEREBY AUTHORIZE THE RELEASE OF ALL INFORMATION RELATING TO MY INCOME TO THE Lukachukai Chapter Government #036 FOR USE IN OBTAINING HOUSING RENOVATION. DATE: Applicant s Signature: **************************************************************************************** ONLY TO BE COMPLETED AND SIGNED BY YOUR EMPLOYER/ GRANTOR: Employee: Employee Salary & Compensation: Position: Gross Rate (Per Hour)/ Grant $ (weekly) $ Contract Agreement $ (weekly) $ Other Compensation $ (weekly) $ Unemployment Comp? $ (weekly) $ Employment Date: Total Compensation $ From: From: To: X52(weeks) per annual $ ALL INFORMATION HERE IN GIVEN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE. EMPLOYER DATE: ADDRESS: SIGNATURE: TITLE: TELEPHONE: Amount

6 6 4. Draw a Map to Resident (Location of Home) & Diagram of the House (Dimension) (BE SPECIFIC AND ACCURATE) W N S E

7 7 AUTHORIZATION FOR RELEASE OF INFORMATION DATE Sir/Madam: I (We), Head of Household Social Security No. Census No. And Spouse Social Security No. Census No. Hereby authorize the Lukachukai Chapter to obtain any information or source documents for completion of my (our) application for housing assistance. I (We) understand and acknowledge this information or source documents will be used in determining my (our) eligibility pursuant to established policies and procedures of the Housing Renovation Assistance Program/Committee. Head of Household Spouse