Apply for Assistance

Family Composition: Name/Relationship/Birthdate/Social Security No. of each person who will reside in your household if you qualify for the Emergency Rental Assistance Program with NCIHA

The following information is requested to determine if you are qualified for federal preferences in accordance with HUD regulations and is subject to verification by NCIHA.

Indicate your present situation

Indicate if you pay for any of the items listed

Income data provided in this section will aid in determining eligibility for the Rental Assistance program. All information is kept confidential and is subject to verification. If NCIHA is unable to verify the information, your application will be considered “incomplete” and returned to you. To avoid delaying your application, please complete this section as thoroughly as possible. MUST INCLUDE: All income sources (AFDC, SSI, UIB, employment, revenue sharing, Prop 1A, etc.) for all household members, over the age of 18, receiving income.

Income data provided in this section will aid in determining eligibility for the Rental Assistance Program. All information is kept confidential and is subject to verification. If NCIHA is unable to verify the information, your application will be considered “incomplete” and returned to you. To avoid delaying your application, please complete this section as thoroughly as possible. MUST INCLUDE: All income sources (AFDC, SSI, UIB, employment, revenue sharing, Prop 1A, etc.) for all household members, over the age of 18, receiving income.

1. GIVING TRUE AND COMPLETE INFORMATION I certify that all the information provided on household composition, income family assets and items for allowances and deductions is accurate and complete to the to the best of my knowledge. I have reviewed all applicable NCIHA forms and certify that the information shown is true and correct. 2. REPORTING CHANGES IN INCOME OR HOUSEHOLD COMPOSITION I know I am required to report changes in income and any changes in the household size when a person moves in or out the unit. I understand the rules regarding guests/ visitors and when I must report anyone who is staying with me. 3. PORTING ON PRIOR HOUSING ASSISTANCE I certify that I have disclosed where I received any previous federal housing assistance and whether or not any money is owed. I certify that for this previous assistance I did not commit any fraud, knowingly misrepresent any information or vacate the unit in violation of the lease. 4. NO DUPLICATE RESIDENCE OR ASSISTANCE I certify that the house or apartment will be my principal residence and will not obtain duplicate federal housing assistance while I am in this current program. 5. COOPERATION I know I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits or verify my true circumstances. Cooperation includes attending pre-scheduled meetings, completing and signing needed forms. I understand failure or refusal to do so, may result in delays, termination of assistance or eviction. 6. CRIMINAL AND ADMINISTRATIVE ACTIONS FOR FALSE INFORMATION I understand that knowingly supplying false, incomplete or inaccurate information is punishable under federal or state criminal law. I understand that knowingly supplying false, incomplete or inaccurate information is grounds for termination of housing assistance and/or termination of tenancy. I certify that I have read and understand the 6 declarations as listed above. I also certify that the information that I have provided is true to the best of my knowledge and that any misrepresentations of information or false statements shall be grounds for termination of my Lease/MHOA.

I hereby certify that I do not own an interest in a house, condominium, cooperative, or building which I could use as a residence (collectively “a Residence”) and that I am currently in need of decent, safe and sanitary housing. If I acquire an ownership interest in a Residence while I am renting a house or apartment from Northern Circle Indian Housing Authority (“NCIHA”), I agree to notify NCIHA of the fact immediately. Further I understand that NCIHA may terminate my lease based on my ownership interest in a Residence. I agree to vacate the house or apartment I am renting from NCIHA immediately, if NCIHA terminates that lease, because I have acquired an interest in a Residence.

Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993. This law is found at 42 U.S.C. 3544. This law requires that you sign a consent form authorizing: (1) HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits. Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household’s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits. Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form. Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age. Persons who apply for or receive assistance under the following programs are required to sign this consent form: PHA-owned rental public housing Turnkey III Homeownership Opportunities Mutual Help Homeownership Opportunity Section 23 and 19(c) leased housing Section 23 Housing Assistance Payments HA-owned rental Indian housing Section 8 Rental Certificate Section 8 Rental Voucher Section 8 Moderate Rehabilitation Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA’s grievance procedures and Section 8 informal hearing procedures. Sources of Information To Be Obtained State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.) U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self employment information and payments of retirement income as referenced at Section 6103(l)(7)(A) of the Internal Revenue Code.) U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].) Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits.

As a resident of Northern Circle Indian Housing Authority, I am authorizing the release of the information requested by NCIHA and understand that it will be used for the purpose of verifying my income.

All Tribes participating in Northern Circle Indian Housing Authority housing programs have established preferences for enrolled members of each individual Rancheria