Transcript
Page 1: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

__________________________ _______/_______APPLICANT NAME TIME DATE

KODIAK ISLAND HOUSING AUTHORITY3137 MILL BAY ROAD, KODIAK, ALASKA 99615

Phone 907-486-8111 * Fax 907-486-4432Toll Free (within Alaska) 1-800-478-5442

Open Monday through Friday (Except Holidays)8:00 A.M. to 12 Noon and 1:00 P.M. to 4:30 P.M.

In October of 1996 congress passed a law entitled the Native American HousingAssistance and Self-Determination Act (NAHASDA) of 1996. Under this new law,effective October 1, 1997, KIHA, an Indian Housing Authority, is required to givepreference in its HUD funded programs to American Indian/Alaska Native (AIAN)families. Non-natives are permitted to participate, but only after Native applicants arehoused. Program information follows:

NAHASDA, under HUD, funds the following housing programs. Preference inadmission is given to Alaska Native/American Indian applicants. Applicants mustpass admission criteria and provide references. All vacancies are filled from a wait list.Rent is based on income.

Mutual Help Homeownership Program - The homes are located in Kodiak and in thesix Native Villages on Kodiak Island. House sizes vary by community, from 2 bedroomto 5 bedroom units. Some locations require a $1,500 down payment. House paymentsare based on income. The homebuyer(s) pay all utilities and are responsible for all homemaintenance and upkeep. Vacancies may exist in some village communities, while otherhave a wait list. Some locations may permit limited admission for Non-Nativeapplicants, but are based on specific criteria.

Page 2: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Kodiak Island Housing Authority Program Limits

The following income limits are the maximum for each program. Your total yearly gross income may not exceed these limits to be eligible.

Family Size

All Programs

1 $40,800 2 $46,650 3 $52,450 4 $58,300 5 $62,950 6 $67,650 7 $72,300

8+ $76,950 How do you file a housing application? You are required to complete an application form. Do not leave any section blank. Mark “N/A” if the section does not apply. The head of household and other adults must sign the application when it is complete. We will assist you with any questions or concerns you may have in completing your application. An incomplete application will delay your eligibility. What information is verified or checked for my housing application? The following information will be verified: Family income, assets, social security numbers, immigration (alien) status, identity of adults, age and relationship of person listed on application if questionable, preference status (if claimed), and/or Alaska Native/American Indian Status (if claimed for preference in admission).

Other information that may be checked includes:

* Criminal History * Prior landlord references * Personal references * Past participation in Federal Housing * Credit History When will I hear on my application? You will be notified of your eligibility. Questions about your application can be answered be calling 486-8111 or 1-800-478-5442. Verbal and/or Written notification of offer will be provided. We require a face-to-face interview with applicant prior to move in.

Page 3: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Notice To Alaska Native/American Indian Applicants

VERIFICATION OF INDIAN BLOOD Applicants for the NAHASDA Rental Assistance Programs and Native applicants who claim preference for admission to the Indian Low Rent/Housing Programs must positively verify Indian blood. Acceptable items of verification include: 1. Certificate of Indian Blood (CIB) issued by the Bureau of Indian Affairs (BIA). 2. Documentation from the Native Alaskan Corporation or tribe in which the individual or their ancestor is enrolled, and proof of relationship to the family member with positive proof of Indian blood. 3. If the applicant is not enrolled in a Native Corporation and does not possess a CIB, but is the

descendant of a person so enrolled, the applicant must show proof of relationship to the ancestor who can prove Indian blood.

Admission to, or preference in, programs can be delayed until proof of Indian Blood is provided. Verification of Indian Blood expedites your application process.

Page 4: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

ITEMS TO BRING TO THE INTERVIEW I. INFORMATION ABOUT YOUR INCOME AND ASSETS

1. Employment Income. For every family or household member who works, bring the following information:

* Name, address, telephone number of the employer. * Three current pay stubs * Other type of income you expect to receive from employment, such as

tips, commissions, profit-sharing programs, etc. * Last three years taxes with all schedules, W-2s and 1099s.

2. Benefit and Support Income. If any member of your family/household receives

any of the following income, state the name, address, and telephone number of the source of the income, and information about the amount received:

* Unemployment Compensation * Social Security * Supplemental Social Security * Veteran’s Benefits * Pension * Disability Income * Native Dividend Income and Stipends * Alimony * Child Support * Welfare or other public assistance * Regular support from family members or friends

3. Amounts in Savings Accounts (including Christmas Clubs, Certificates of

Deposit, IRA and Keogh Accounts) and Checking Accounts. Bring your current bank statements.

4. Real Estate You Own - Provide information about the location, current value of

the property, any income you receive and what expenses you have for the property. (Bring last year's Schedule E from your income tax return.)

5. Stocks, Bonds, Trusts, Other Investments. Provide account numbers and/or

statements of value for investments and information for any income earned from investments.

6. Life Insurance Policies – Provide the company name and policy numbers.

7. Other Income - Provide the name, address, and telephone number and the amount

of the source of any other income.

8. If you have sold or given away any assets in the past two years (such as giving a property or an amount of money to another family member), please bring information about those assets.

Page 5: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

II. INFORMATION ABOUT FAMILY MEMBERS 1. For Adults - Provide a current picture ID.

2. For Children - Provide birth certificates, custody agreement, adoption papers, or other proof that the children are members of this household.

3. For Full-time Students - If any family members are 18 years of age or older and

attending school full time, provide the school location.

4. Handicap or Disability. If any member of your family is handicapped or disabled, bring information about any income the member receives because of his/her handicap/disability.

5. If any family member is NOT a U.S. citizen by birth, naturalized citizen or a

national of the United States, provide proof of immigration status. III. EXPENSES

Bring information regarding any of the following expenses.

1. Medical expenses not covered by insurance. (Elderly families only)

2. Medical insurance premiums or amounts deducted from your benefits for medical insurance. (Elderly families only)

3. Child care expenses for your children while you work or go to school.

4. Expenses to care for a handicapped or disabled family member.

Page 6: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENTOffice of the Inspector General

May, 1988 THINGS YOUP-88-2 SHOULD KNOW

Don't Risk your chances for Federally assisted housing by providing false, incomplete orinaccurate information on your application and recertification forms.

Purpose This is to inform you that there is certain information you must providewhen applying for assisted housing. There are penalties that apply if youknowingly omit information or give false information.

Penalties for The United States Department of Housing and Urban DevelopmentCommitting (HUD) places a high priority on preventing fraud. If your application orFraud recertification forms contain false or imcomplete information, you may

be:* Evicted from your apartment or house;* Required to repay all overpaid rental assistance you received;* Fined up to $10,000;* Imprisoned for up to 5 years; and/or* Prohibited from receiving future assistance.

Your State and local governments may have other laws and penalties as well.

Asking When you sit down with the person who fills out your application, youQuestions should know what is expected of you. If you do not understand

something, say so. That person can answer your question or find outwhat the answer is

Completing the When you give your answers to application questions, you must includeApplication the following information:Income * All sources of money you and any member of your family receive

(wages, welfare payments, alimony, social security, pension, etc);* Any money you receive on behalf of your children (child support,

social security for children, etc);* Income from assets (interest from a savings account, credit union,

or certificate of deposit; dividends from stocks, etc);* Earnings from second job or part time job;* Any anticipated income (such as a bonus or pay raise you expect

to receive).Assets * All bank accounts, savings bonds, certificates of deposit, stocks,

real estate, etc., that are owned by you and any adult member of your family/household who will be living with you.

* Any business or asset you sold in the last two years for less than itsfull value, such as your home to your children.

ThingsYouShouldKnow.xls1

Page 7: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Family/Household The names of all the people (adults and children) who willMembers actually be living with you, whether or not they are related to you.

Signing the * Do not sign any form unless you have read it, understand it, andApplication are sure everything is complete and accurate.

* When you sign application and certification forms, you are claimingthat they are complete to the best of your knowledge and belief.

* You are committing fraud if you sign a form knowing that itcontains false or misleading information.

* Information you give on your application will be verified by yourhousing agency. In addition, HUD may do computer matches ofthe income you report with various Federal, State or privateagencies to verify that it is correct.

Recertifications You must provide updated information at least once a year. Someprograms require that you report any changes in income orfamily/household composition immediately. Be sure to ask when youmust recertify. You must report on recertification forms:* All income changes, such as pay increases or benefits, change of

job, loss of job, loss of benefits, etc., for all adult family/householdmembers.

* Any family/household member who has moved out.* All assets that you or your family/household members own and

any asset that was sold in the last 2 years for less than its fullvalue.

Beware of You should be aware of the following fraud schemes:Fraud * Do not pay any money to file an application.

* Do not pay any money to move up on the waiting list.* Do not pay for anything not covered by your lease.* Get a receipt for any money you pay.* Get a written explanation if you are required to pay any money

other than rent (such as maintenance charges).

Reporting If you are aware of anyone who has falsified an application, or if anyoneAbuse tries to persuade you to make false statements, report them to the

manager of your project or PHA. If you cannot report to the manager, callthe local HUD office in Alaska at (907)677-9886. This is not a toll freenumber. You can also write to the HUD HOTLINE, Room 8254,451 Seventh Street S.W., Washington, DC 20410

To report fraud and abuse in the Kodiak area, please contactRhea Eisenhauer, Housing Manager for Kodiak Island HousingAuthority, at (907)486-8111 or 1-800-478-5442.

ThingsYouShouldKnow.xls1

Page 8: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Date RcvdTime RcvdStaff Initials

What Village are you interested in?

APPLICANT:APPLICANT’S FULL NAME: TELEPHONE NUMBER:MAILING ADDRESS: RESIDENCE ADDRESS:

HOUSING INFORMATION: (Where you currently live)MONTHLY RENT AMOUNT ELECTRIC OIL OTHER UTILITIES (specify):

LENGTH OF STAY AT CURRENT RESIDENCE LANDLORD’S NAME LANDLORD MAIL ADDRESS PHONE NO.

HOUSEHOLD COMPOSITION: Complete this information for everyone who will live in the unit. List yourself first. (If anyone is pregnant, list “unborn child” beneath pregnant person’s name).

Date of Relationship Social Security US AK Native/Birth to Applicant Number Citizen Am Indian

IF YOU ARE MARRIED AND HAVE NOT LISTED YOUR SPOUSE, PLEASE EXPLAIN WHY AND STATE YOUR SPOUSE’S NAME AND ADDRESS. Explanation: Spouse’s name and address: Please list all other names used by you or other adults (18 and over)

Have you or a member of your household ever been arrested, charged or convicted of any crime other thana traffic violation? Yes No If yes, please explain:

Have you ever been evicted or had a lease terminated? Yes No. If yes, please explain.

Have you ever participated in any federally subsidized housing programs? Yes NoIf yes, from to ; Name of Housing Authority

City, State

Do you owe money to another Housing Agency or Landlord? Yes No. If yes, please explain.

KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, AK 99615-7032

907-486-8111 OR TOLL FREE 1-800-478-5442

APPLICATION FOR MUTUAL HELP HOUSING

Sex(M/F)LEGAL NAME

Page 9: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

If you are 62 or over, disabled or handicapped, do you have medical expenses NOT REIMBURSED by insurance or other programs?If yes, complete information below. Proof of medical expenses must be provided. Provider/Type of Expense:

Does anyone in your family have a disability which requires a unit with special features? If so, what features would you require?

If you have children, under age 13, do you pay childcare to enable you to work or attend school? If yes, complete informationbelow. Proof of expenses must be provided.

Name & Mailing Address of Child Care Provider:

FAMILY INCOME: All money received by every person in household. If self employed or seasonally employed, provide proof of income for the past three years. List gross income for all family members (all types: wages, self-employment, government benefits, APA, Child Support, Native Corp Dividends, etc.

Hourly Weekly Monthly Year toRate Rate Amount Date Income

Is Anyone Self Employed: Yes No If Yes, what type of business?

Which family members received or will receive the Alaska Permanent Fund Dividend?

ASSETS: Identify assets owned by your family in the section below. If you answer yes, please provide complete information. Include assets of all family members. Use additional sheets of paper if necessary.

YES NO

NATIVE CORPORATION STOCK OR OTHER STOCK

Number of Shares In Whose NameCorporation Name

BANK ACCOUNTS: Name of BankName on AccountChecking Acct # Savings Acct #

REAL PROPERTY or other real estate: (Provide copy of last assessment) Owner of property: Location of property:

LIFE INSURANCE (Other than term) Provide copy of last statement

BONDS: (Include US Savings Bonds, provide copy of bonds) Provide proof of value.

OTHER INVESTMENTS: (IRA’s, retirement accounts or the like)

OTHER ASSETS: (May include vehicles, 4-wheelers, etc) Please describe.

VALUE

Family Member Name Employer/Income Source

ASSET

Page 10: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Have you sold or given away any asset in the past two years? Yes No If yes, explain:

LIST LAST THREE RESIDENCES - DO NOT INCLUDE CURRENT RESIDENCELandlord Landlord DatePhone # Phone # Occupied

APPLICANT - LIST LAST THREE EMPLOYERS IF CURRENT EMPLOYMENT LESS THAN 2 YEARS

SPOUSE/OTHER ADULT: LIST LAST THREE EMPLOYERS IF CURRENT EMPLOYMENT LESS THAN 2 YEARS

LIST THREE PERSONAL REFERENCES (One may be a relative)

Do you pay someone to care for a disabled family member while you work? Yes No

APPLICANTS CERTIFICATION: W/We certify that the information given to the Kodiak Island Housing Authority on the application is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information is punishable under Federal Law. I/We also understand that giving false statements or information is grounds for termination of housing assistance and termination of occupancy.

Expenses You PayFamily Member

Landlord Name / AddressAddress

of Residence

Supervisor Name

Name of Employer Address Phone Supervisor Name

Address Phone #Name

PhoneAddressName of Employer

Page 11: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Signature of Applicant Date

Signature of Co-Applicant Date

Signature of Other Adult Member Date

Signature of Other Adult Member Date

Kodiak Island Housing Authority does not discriminate against any person because of race, color, religion, sex, handicap, familial status or national origin. We do business in accordance with the Federal Fair Housing Law.

If you believe you have been discriminated against, you may call the Fair Housing & Equal Opportunity National Toll-Free Hot Line at 1-800-478-4692 or 1-907-271-4663.

Notice: Any attempt to obtain Federal housing assistance by false information, impersonation, failure to disclose, orother fraud (and any act of assistance to attempt such ) is a crime.

EQUAL HOUSING OPPORTUNITYWe Do Business in Accordance

With the Federal Fair Housing Law

Page 12: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Head of Household: Client No.:

I authorize and direct any federal, state or local agency and any organization, business, or individual to Kodiak IslandHousing Authority (KIHA) any information or materials needed to complete and verify my application for, or participationin, any KIHA housing program. Verifications and inquiries that may be requested include but are not limited to:

* IDENTITY AND MARITAL STATUS * INCOME FROM ANY SOURCE* CREDIT HISTORY * ASSETS OF ANY KIND, INCLUDING ASSETS* POLICE RECORDS AND CRIMINAL HISTORY ASSETS DISPOSED OF WITHIN THE LAST* EMPLOYMENT INCOME TWO (2) YEARS* RESIDENCES AND RENTAL ACTIVITY * MEDICAL OR CHILD CARE ALLOWANCES

* PAST AND PRESENT LANDLORDS * PAST AND PRESENT EMPLOYERS* COURTS AND POST OFFICES * DEPT. OF HEALTH & SOCIAL SERVICES* SCHOOLS AND COLLEGES * DEPT. OF LABOR AND WORKFORCE* LAW ENFORCEMENT AGENCIES DEVELOPMENT* UTILITY COMPANIES * DEPT. OF EDUCATION & EARLY* VETERANS ADMINISTRATION DEVELOPMENT* BANKS AND FINANCIAL INSTITUTIONS * SOCIAL SECURITY ADMINISTRATION* AK PERMANENT FUND CORPORATION * MEDICAL AND CHILD CARE PROVIDERS* PRIVATE SOCIAL SERVICE AGENCIES * RETIREMENT SYSTEMS* INDIVIDUALS PROVIDING REFERENCES OR * PAYEES, TRUSTEES

OTHER DOCUMENTATION * CREDIT REPORTING COMPANIES

Conditions: I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for, and continued participation in, a housing program. I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in effect for 15 monthsfrom the date signed.

Signature of Head of Household Print Name Date

Signature of Spouse/Co-Tenant Print Name Date

Signature of Adult Member Print Name Date

Groups or Individuals That KIHA May Contact

Release of InformationAuthorization for

Kodiak Island Housing Authority3137 Mill Bay Road

Kodiak, Alaska 99615Phone: (907)486-8111 Fax: (907)486-4432

Page 13: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Original is retained by the requesting organization. form HUD-9886 (7/94)ref. Handbooks 7420.7, 7420.8, & 7465.1

Authorization for the Release of Information/Privacy Act Noticeto the U.S. Department of Housing and Urban Development (HUD)and the Housing Agency/Authority (HA)

Persons who apply for or receive assistance under the followingprograms are required to sign this consent form:

PHA-owned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHA-owned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consentform may result in the denial of eligibility or termination ofassisted housing benefits, or both. Denial of eligibility or termi-nation of benefits is subject to the HA’s grievance procedures andSection 8 informal hearing procedures.

Sources of Information To Be ObtainedState Wage Information Collection Agencies. (This consent islimited to wages and unemployment compensation I have re-ceived during period(s) within the last 5 years when I havereceived assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent islimited to the wage and self employment information and pay-ments 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 islimited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current andformer employers concerning salary and wages and (b) financialinstitutions concerning unearned income (i.e., interest and divi-dends). I understand that income information obtained from thesesources will be used to verify information that I provide indetermining eligibility for assisted housing programs and the levelof benefits. Therefore, this consent form only authorizes releasedirectly from employers and financial institutions of informationregarding any period(s) within the last 5 years when I havereceived assisted housing benefits.

Authority: Section 904 of the Stewart B. McKinney HomelessAssistance Amendments Act of 1988, as amended by Section 903of the Housing and Community Development Act of 1992 andSection 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 verifi-cation of salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensa-tion claim information from the state agency responsible forkeeping that information; (3) HUD to request certain tax returninformation from the U.S. Social Security Administration and theU.S. Internal Revenue Service. The law also requires independentverification of income information. Therefore, HUD or the HAmay request information from financial institutions to verify youreligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUDand the above-named HA to request income information from thesources listed on the form. HUD and the HA need this informationto verify your household’s income, in order to ensure that you areeligible for assisted housing benefits and that these benefits are setat the correct level. HUD and the HA may participate in computermatching programs with these sources in order to verify youreligibility and level of benefits.

Uses of Information to be Obtained: HUD is required to protectthe income information it obtains in accordance with the PrivacyAct of 1974, 5 U.S.C. 552a. HUD may disclose information(other than tax return information) for certain routine uses, such asto other government agencies for law enforcement purposes, toFederal agencies for employment suitability purposes and to HAsfor the purpose of determining housing assistance. The HA is alsorequired to protect the income information it obtains in accordancewith any applicable State privacy law. HUD and HA employeesmay be subject to penalties for unauthorized disclosures or im-proper uses of the income information that is obtained based on theconsent form. Private owners may not request or receiveinformation authorized by this form.

Who Must Sign the Consent Form: Each member of yourhousehold who is 18 years of age or older must sign the consentform. Additional signatures must be obtained from new adultmembers joining the household or whenever members of thehousehold become 18 years of age.

PHA requesting release of information; (Cross out space if none) IHA requesting release of information: (Cross out space if none)(Full address, name of contact person, and date) (Full address, name of contact person, and date)

U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian Housing

Page 14: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Original is retained by the requesting organization. form HUD-9886 (7/94)ref. Handbooks 7420.7, 7420.8, & 7465.1

Signatures:

_____________________________________________ ______________Head of Household Date

___________________________________________Social Security Number (if any) of Head of Household

__________________________________________________ _______________Spouse Date

__________________________________________________ _______________Other Family Member over age 18 Date

__________________________________________________ _______________Other Family Member over age 18 Date

Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form forthe purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs thatreceive income information under this consent form cannot use it to deny, reduce or terminate assistance without firstindependently verifying what the amount was, whether I actually had access to the funds and when the funds were received. Inaddition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

__________________________________________________ ________________Other Family Member over age 18 Date

Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses ofinformation collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfullyrequests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not morethan $5,000.

Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, againstthe officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use.

Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this informationby the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the FairHousing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants andparticipants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income andother information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your familywill pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoringHUD-assisted housing programs, to protect the Government’s financial interest, and to verify the accuracy of the information you provide.This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatoryinvestigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permittedor required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you,and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household memberssix years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provideany of the requested information may result in a delay or rejection of your eligibility approval.

Page 15: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

KODIAK ISLAND HOUSING AUTHORITY3137 MILL BAY ROAD, KODIAK, ALASKA 99615

(907)486-8111 or (800)478-5442

REPORTING YOUR INCOME

Applicants for assisted housing programs are REQUIRED to fully disclose and reportassets and all income or money received by the household, no matter the source.

You MUST report all assets and income at initial application, on every annualrecertification, and when there is a change in your income.

Changes in income must be reported in writing WITHIN TEN (10) DAYS of yourknowing about the change.

FAILURE TO REPORT ASSETS OR INCOME, DELIBERATEMISREPRENSENTATION OF ASSETS OR INCOME, AND/OR FALSIFYINGINCOME IS FRAUDULENT AND A CRIME.

If you fail to report and disclose your assets and income as required, you may be:

• Prosecuted for fraud

• Your application may be denied for up to 3 years

• Failure to report any changes in income, assets or family composition, asrequired, shall be cause for retroactive rent charges and/or termination of a leaseagreement.

DO NOT risk your opportunity to receive housing assistance by failing to disclose yourincome.

Page 16: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

KODIAK ISLAND HOUSING AUTHORITYVERIFICATION FORM

Federal law requires us to verify the income of families applying for admission to federally aided housing projects wemanage. We ask your cooperation in supplying information regarding the person named below. Please complete thesections as indicated below, date, sign and return promptly in the envelope enclosed. THANK YOU FOR YOURASSISTANCE.

IDENTITY OF APPLICANT (S)

NAME OF APPLICANT SOCIAL SECURITY # NAME OF CO-APPLICANT SOCIAL SECURITY # I/We hereby authorize release to the Kodiak Island Housing Authority of all information regarding my/our income andassets. I/We understand that this information will be kept confidential. I/We am/are willing that a photocopy of thisauthorization be accepted with the same authority as the original.

APPLICANT SIGNATURE DATE CO-APPLICANT SIGNATURE DATE

APPLICANT - DO NOT WRITE BELOW THIS LINE*************************************************************************************************************************************

EMPLOYMENT VERIFICATION ----- NAME OF EMPLOYEE:

DATE HIRED/

Date Terminated POSITION HELDPAY

RATE

# HOURS PERWEEK

GROSS YTDEARNINGS

GROSS PRIORYEAR EARNINGS

Other:

PUBLIC ASSISTANCE VERIFICATION (ATAP/APA/GA/TA)

Case # Please attach print out for

ALASKA SENIOR ASSISTANCE PROGRAM / VETERANS BENEFITS/RETIREMENT:Amount of monthly benefits: $ Date benefits began:

Date Sent: Title

Sent To: Signature

PLEASE RETURN TO: Kodiak Island Housing Authority3137 Mill Bay Rd.Kodiak, AK 99615Attn: Fax (907) 486-4432 or 486-8723

Page 17: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

KODIAK ISLAND HOUSING AUTHORITY3137 Mill Bay Road, Kodiak, AK 99615Phone: 907-486-8111 Fax: 907-486-4432

APPLICANT\TENANT CERTIFICATION

Giving True and Complete Information

I/we certify that all the information provided about household composition, Social Security numbers, U.S. Citizenship,income, family assets and items for allowance and deductions, is/are accurate and complete to the best of my/our knowledge.I/we certify that the information given is true and correct.

Reporting Changes in Income or Household Composition

I/we know I/we am/are required to report within 10 days, in writing, any changes in income and any changes in householdsize (when a person moves in or out of the unit). I/we understand the rules regarding guests\visitors for current KIHAprograms and that I/we must report anyone who is staying with me/us.

Reporting on Prior Housing Assistance

I/we certify that I/we have disclosed where I/we received any previous Federal housing assistance and whether (if) I/we oweany money to another Federal program. I/we certify that, for this previous Federal assistance, I/we did not commit anyfraud, knowingly misrepresent any information, or vacant (vacate) the unit in violation of the lease.

No Duplicate Residence or Assistance

I/we certify that the house or apartment for which I/we will receive assistance from KIHA, or for which I/we am/are currentlyreceiving assistance from KIHA, will be my/our principal residence. I/we will not obtain duplicate Federal housingassistance while I/we am/are in this current program. I/we will not live anywhere else without notifying KIHA immediately inwriting. I/we will not sublease my/our assisted residence.

Cooperation

I/we know I/we am/are required to cooperate in supplying all information needed to determine my/our eligibility, level ofbenefits, or verification of my true circumstances. Cooperation includes attending pre-scheduled meetings and completingand signing needed forms. I/we understand failure or refusal to do so may result in delays, denial of assistance, terminationof assistance, or eviction.

Criminal and Administrative Action for False Information

I/we understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal or Statecriminal law. I/we understand that knowingly supplying false, incomplete, or inaccurate information is grounds for denial ofassistance, termination of housing assistance and/or termination of tenancy.

Signature and Date of Household Adults

1.______________________________________________ Date:______________________

2.______________________________________________ Date: ______________________

3.______________________________________________ Date: ______________________

Page 18: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

STATE OF ALASKADEPARTMENT OF LABOR

UNEMPLOYMENT INFORMATION BENEFITSRELEASE OF INFORMATION FORM

Federal law requires us to verify the income of families applying for admission to federally aidedhousing projects we manage. We ask your cooperation in supplying information regarding theperson named below. Please complete the sections as indicated below, date, sign and returnpromptly in the envelope enclosed. THANK YOU FOR YOUR ASSISTANCE.

I________________________________ Social Security #________________

hereby request and authorize that you release to Kodiak Island Housing Authority 3137 Mill BayRoad, Kodiak, Alaska 99615 any data from my file relating to the items specified below inaddition to, information concerning my work history and Unemployment Insurance Claim asrequested. Please state whether or not I am currently receiving Unemployment CompensationBenefits.

Signature: Date:

FOR ADOL USE ONLY - DO NOT WRITE BELOW THIS LINEIN REGARD TO THE ABOVE NAMED PERSON:

1. Has He/She Registered For Work with Job Service? YES NO

2. Has He/She Filed A Current Claim For Unemployment Benefits?YES NO

3. On What Date Was The Claim Started? _____/_____/_____

4. Last Claim Benefits For Week Ending? _____/____/______

5. The Last Paid Benefits For Week Ending? _____/_____/____/

6. Actual Amount Of Weekly Benefits? $_____________

7. Is He/She Eligible For Extended Benefits? YES_____ NO______ If So, How Much? $____________

8. The Amount Of Benefits Remaining In The Benefits Year Is$_________________

9. The Total Amount of Benefits Paid in the Prior Year is$______________

________________________________________ _____________________ADOL REPRESENTATIVE DATE

From: Kodiak Island Housing Authority 3137 Mill Bay Road Kodiak, Alaska 99615 (907) 486-8111

KIHA REPRESENTATIVE

Page 19: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

Alaska Department of Revenue Permanent Fund Dividend Division

Request for Income Verification

Use this form only if you or the child(ren) you sponsored did not receive a Permanent Fund Dividend. (If you were garnished do not use this form as you must report the full amount as income)

I did not receive a PFD for the following year ______________________ The child(ren) listed below whom I sponsored did not receive a PFD for the following year ________________

Your Signature is Required I authorize the Permanent Fund Dividend Division to release of information regarding the status of my PFD to the following

Housing Agency – send or deliver this completed form to the Juneau Dividend Information Office listed below:

Alaska Department of Revenue Permanent Fund Dividend Division PO Box 110461 Juneau, AK 99811-0460 Send all self addressed envelope with this request www.pfd.state.ak.us Verf Request (New 8/02)

Your First Name

MI Last Name

Social Security Number

Date of Birth Daytime Telephone Number Message Telephone Number

Your First Name

MI

Last Name

Social Security Number

Date of Birth (MM/DD/YY)

Child’s First Name

MI

Last Name

Social Security Number

Date of Birth (MM/DD/YY)

Child’s First Name

MI

Last Name

Social Security Number

Date of Birth (MM/DD/YY)

Child’s First Name

MI

Last Name

Social Security Number

Date of Birth (MM/DD/YY)

Child’s First Name

MI

Last Name

Social Security Number

Date of Birth (MM/DD/YY)

Child’s First Name

MI

Last Name

Social Security Number

Date of Birth (MM/DD/YY)

Your Signature

Date

For PFD Office Use ONLY Correct, applicant(s) did not receive a PFD Incorrect, applicant(s) received a PFD Amount _________________ Signature of PFD Rep. ____________________________________ Date ________________

Page 20: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

KODIAK ISLAND HOUSING AUTHORITY3137 MILL BAY ROAD, KODIAK, ALASKA 99615

PHONE (907) 486-8111 FAX (907) 486-4432

Date: ___________________

_____________________________

_____________________________

_____________________________

Dear Sirs:

We are required to verify the incomes of all members of families applying for admissionin the Federally Assisted Housing Programs we operate, and periodically to re-examinefamily incomes. To comply with this requirement, we ask your cooperation in supplyingthe information requested below regarding the referenced individual. This informationwill be used only in determining the eligibility status and monthly payment.

Please provide the amount of Native Corporation Stock Disbursement issued to:

______________________________________SS# ________________________and the date issued for the past twelve (12) months.

Amount of Distribution Date Issued

$_____________ _____________

$_____________ _____________

$_____________ _____________

$_____________ _____________

Your prompt return of this letter is appreciated. This above recipient’s housing assistancewill be pending until this information is received.

Sincerely,

Housing AdvisorCc: fileI authorize the release of the above requested information:__________________________________Signature Date

Page 21: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

DO NOT COMPLETE UNLESS YOU ARE RECEIVING SOCIAL SECURITYBENEFITS

TO: SOCIAL SECURITY ADMINISTRATION

_________________________________________________ ___________Name that appears on Social Security Check Date of Birth

______________________________________ Social Security Number and Claim #, if different

I authorize the Social Security Administration to release information of records about meto:

Kodiak Island Housing Authority ATTENTION:3137 Mill Bay Road Kodiak Island Housing AuthorityKodiak, Alaska 99615 is an Indian Housing Authority.(907) 486-8111 phone We do not have access to TASS.(907) 486-4432 fax Thank you.

I want this information released because: Eligibility for Federally SubsidizedHousing

Please release the following information:

Social Security NumberIdentifying information(including date and place of birth, parents names)

X Monthly Social Security benefit amountX Monthly Supplemental Security Income Payment amount

Information about benefit/payments I received from ______to_________Information about Medicare claim/coverage from ________to_________Medical RecordsRecords from my file(specify) ____________________________________Other (specify) _________________________________________________

I am the individual to whom the information/record applies or the parent or legalguardian of that person. I know that if I make any representation, which I know is falseto obtain information from Social Security Records, I could be punished by fine orimprisonment or both.

Signature: (show signatures, names, and addresses of two people if signed by mark.)

Date:____________________ Relationship:____________________

Page 22: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

KODIAK ISLAND HOUSING AUTHORITY3137 MILL BAY ROAD, KODIAK, ALASKA 99615

Phone 907-486-8111 or FAX 907-486-4332

Date

Landlord Reference: For KIHA use only

Completed by Source and ReturnedTO:

Completed via phone with sourceon

by:

The named head of household has authorized you to disclose all of the information requested regarding their tenant history. The release of information is attached.

Please note that we will need this information returned within ten (10) business days from the above date. We appreciate your assistance in helping us serve our clients more effectively.

Applicant (tenant) Name:

Rental Address:

Are you the applicant’s current landlord? Yes No Date of Move in

Are you a friend or relative of the applicant? Yes No Date of Move out

Does (did) the tenant have a lease? Yes No

Rent Payment HistoryAmount of Monthly Rent Is rent paid on time? Was the rent ever late? How often?

$ Yes No Yes No

Have (had) you ever begun or completed eviction proceedings? Yes No

If yes, for non-payment or good cause (circle one)? If good cause, please explain:

Have tenant-paid utilities ever been disconnected? Yes No

Is unit kept clean, safe and sanitary? Yes No

Has udit been Damaged? Yes No

If Yes, describe the damage

Page 23: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

How often was unit damaged? What was the repair cost? $

Did tenant pay for damage? Yes No

Did you keep the security deposit? Yes No

Did Tenant have problems with rodent/insect infestation? Yes No

Did tenant’s housekeeping contribute to infestation? Yes No

General

Was the tenant listed on the lease? Yes No

Did the tenant, family members or guest(s) damage or vandalize the common areas?Yes No

Did the tenant, family members or guest(s) engage in any criminal activity including drug-related criminal activitiy in the building or unit? Yes No

Has the tenant given you any false information? Yes No

DId the tenant, family members or guest(s) act in a physically violent and/or verbally abusive manner toward neighbors, yourself or your staff? Yes No

Would you lease a unit to this tenant again? Yes No

If no, please explain:

Additional Comments:

Name of person completing this form: Telephone

Title: Date:

Kodiak Island Housing Authority does not discriminate against any person because of race, color, religion, sex, handicap, familial status or national origin. We do business in accordance with the Federal Fair Hous-ing Law. If you believe you have been discriminated against, you may call the Fair housing & Equal Opportunity National Toll-Free Line at 800-424-8590 or 800-442-0226.

Page 24: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

KODIAK ISLAND HOUSING AUTHORITY3137 MILL BAY ROAD

KODIAK, ALASKA 99615

DECLARATION OF CITIZEN OR NON-CITIZEN STATUS

Notice to applicants and tenants: In order to be eligible to receive the housing assistancesought, each applicant for, or recipient of, housing assistance must be lawfully within the U.S.Please read the Declaration statement carefully and sign and return to the Housing Authority at3137 Mill Bay Road, Kodiak, Alaska 99615. Please feel free to consult with an immigrationlawyer or other immigration expert of your choosing.

I, certify, under penalty of perjury 1/ , that, to the bestof my knowledge, I am lawfully within the United States because (please check the appropriate box):

I am a citizen by birth, a naturalized citizen or a national of the United States; or

I have eligible immigration status that I am 62 years of age or older. Attach evidence of proofof age 2/; or

I have eligible immigration status as checked below (see reverse side of this form forexplanations). Attach INS document(s) evidencing eligible immigration status and signedverification consent form.

Immigration status under §§101(a)(15) or 101(a)(20) of the Immigration andNationality Act (INA) 3/; or

Permanent residence under §249 of INA 4/; or

Refugee, asylum, or conditional entry status under §§207, 208 or 203 of the INA 5/; or

Parole status under §§212(d)(5) of the INA 6/; or

Threat to life or freedom under §243(h) of the INA 7/; or

Amnesty under §245A of the INA 8/.

_____________________________________ (Signature of Family Member) (Date)

Check box on left if signature is of adult residing in the unit who is responsible for child namedon statement above.

HA: Enter INS\SAVE Primary Verification #: Date:

Page 25: KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA

1/ Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses adocument or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdictionof any department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than fiveyears, or both.

The following footnotes pertain to non-citizens who declare immigration status in one of the following categories:

2/ Eligible immigration status and 62 years of age or older. For non-citizens who are 62 years of age or older orwho will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19,1995. If you are eligible and elect to select this category, you must include a document providing evidence ofproof of age. No further documentation of eligible immigration status is required.

3/ Immigration status under §§101(a)(15) or 101(a)(20) of INA. A non-citizen lawfully admitted for permanentresidence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as definedby §101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This categoryincludes a non-citizen under §§210 or 210A or the INA (8 U.S.C. 1160 or 1161), [special agricultural workerstatus], who has been granted lawful temporary resident status.

4/ Permanent residence under §249 of INA. A non-citizen who entered the U.S. before January 1, 1972, or suchmater date as enacted by law, and had continuously maintained residence in the U.S. since then, and who is notineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of anexercise of discretion by the Attorney General under §249 of the INA (8 U.S.C 1259) [amnesty granted underINA 249].

5/ Refugee, asylum, or conditional entry status under §§207, 208 or 203 of INA. A non-citizen who is lawfullypresent in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant tothe granting of asylum (which has not been terminated) under §208 of the INA (8 U.S.C. 1158) [asylum status];or as a result of being granted conditional entry under §203(a)(7) of the INA (U.S.C. 1153(a)(7) before April 1,1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because ofbeing uprooted by catastrophic national calamity [conditional entry status].

6/ Parole status under §212(d)(5) of INA. A non-citizen who is lawfully present in the U.S. as a result of anexercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the publicinterest under §212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status].

7/ Threat to life or freedom under §243(h) of INA. A non-citizen who is lawfully present in the U.S. as a result ofthe Attorney General's withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h)) [threat to life orfreedom].

8/ Amnesty under §245A of INA. A non-citizen lawfully admitted for temporary or permanent residence under§245A of the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A].

Instructions to Housing Authority: Following verification of status claimed by persons declaring eligibleimmigration status (other than for non-citizens age 62 or older and receiving assistance on June 19, 1995), HAmust enter INS|SAVE Verification Number and date that it was obtained. A HA signature is not required.

Instructions to Family Member For Completing Form: On opposite page, print or type first name, middleinitial(s), and last name. Place an "X" or "√" in the appropriate boxes. Sign and date at bottom of page. Place an"X" or "√" in the box below the signature if signature is by the adult residing in the unit who is responsible forChild.


Top Related