kodiak island housing authority 3137 mill bay road, kodiak, alaska

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__________________________ _______/_______ APPLICANT NAME TIME DATE KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA 99615 Phone 907-486-8111 * Fax 907-486-4432 Toll 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 Housing Assistance and Self-Determination Act (NAHASDA) of 1996. Under this new law, effective October 1, 1997, KIHA, an Indian Housing Authority, is required to give preference in its HUD funded programs to American Indian/Alaska Native (AIAN) families. Non-natives are permitted to participate, but only after Native applicants are housed. Program information follows: NAHASDA, under HUD, funds the following housing programs. Preference in admission is given to Alaska Native/American Indian applicants. Applicants must pass 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 the six Native Villages on Kodiak Island. House sizes vary by community, from 2 bedroom to 5 bedroom units. Some locations require a $1,500 down payment. House payments are based on income. The homebuyer(s) pay all utilities and are responsible for all home maintenance and upkeep. Vacancies may exist in some village communities, while other have a wait list. Some locations may permit limited admission for Non-Native applicants, but are based on specific criteria.

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Microsoft Word - Document1__________________________ _______/_______ APPLICANT NAME TIME DATE
KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA 99615
Phone 907-486-8111 * Fax 907-486-4432 Toll 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 Housing Assistance and Self-Determination Act (NAHASDA) of 1996. Under this new law, effective October 1, 1997, KIHA, an Indian Housing Authority, is required to give preference in its HUD funded programs to American Indian/Alaska Native (AIAN) families. Non-natives are permitted to participate, but only after Native applicants are housed. Program information follows:
NAHASDA, under HUD, funds the following housing programs. Preference in admission is given to Alaska Native/American Indian applicants. Applicants must pass 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 the six Native Villages on Kodiak Island. House sizes vary by community, from 2 bedroom to 5 bedroom units. Some locations require a $1,500 down payment. House payments are based on income. The homebuyer(s) pay all utilities and are responsible for all home maintenance and upkeep. Vacancies may exist in some village communities, while other have a wait list. Some locations may permit limited admission for Non-Native applicants, but are based on specific criteria.
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.
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.
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.
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.
U.S. DEPARTMENT OF HOUSING AND URBAN DEVELOPMENT Office of the Inspector General
May, 1988 THINGS YOU P-88-2 SHOULD KNOW
Don't Risk your chances for Federally assisted housing by providing false, incomplete or inaccurate information on your application and recertification forms.
Purpose This is to inform you that there is certain information you must provide when applying for assisted housing. There are penalties that apply if you knowingly omit information or give false information.
Penalties for The United States Department of Housing and Urban Development Committing (HUD) places a high priority on preventing fraud. If your application or Fraud 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, you Questions should know what is expected of you. If you do not understand
something, say so. That person can answer your question or find out what the answer is
Completing the When you give your answers to application questions, you must include Application 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 its full value, such as your home to your children.
ThingsYouShouldKnow.xls 1
Family/Household The names of all the people (adults and children) who will Members 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, and Application are sure everything is complete and accurate.
* When you sign application and certification forms, you are claiming that they are complete to the best of your knowledge and belief.
* You are committing fraud if you sign a form knowing that it contains false or misleading information.
* Information you give on your application will be verified by your housing agency. In addition, HUD may do computer matches of the income you report with various Federal, State or private agencies to verify that it is correct.
Recertifications You must provide updated information at least once a year. Some programs require that you report any changes in income or family/household composition immediately. Be sure to ask when you must 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/household members.
* 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 full value.
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 anyone Abuse 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, call the local HUD office in Alaska at (907)677-9886. This is not a toll free number. 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 contact Rhea Eisenhauer, Housing Manager for Kodiak Island Housing Authority, at (907)486-8111 or 1-800-478-5442.
ThingsYouShouldKnow.xls 1
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 than a 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 No If 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
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 information below. 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 to Rate 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
Number of Shares In Whose Name Corporation Name
BANK ACCOUNTS: Name of Bank Name on Account Checking 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
ASSET
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 RESIDENCE Landlord Landlord Date Phone # 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 / Address Address
Address Phone #Name
PhoneAddressName of Employer
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, or other fraud (and any act of assistance to attempt such ) is a crime.
EQUAL HOUSING OPPORTUNITY We Do Business in Accordance
With the Federal Fair Housing Law
Head of Household: Client No.:
I authorize and direct any federal, state or local agency and any organization, business, or individual to Kodiak Island Housing Authority (KIHA) any information or materials needed to complete and verify my application for, or participation in, 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 months from 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 Information Authorization for
Kodiak Island Housing Authority 3137 Mill Bay Road
Kodiak, Alaska 99615 Phone: (907)486-8111 Fax: (907)486-4432
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 Notice to 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 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 termi- nation 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 re- ceived 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 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 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 divi- dends). 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.
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 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 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 im- proper 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.
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 Housing and Urban Development Office of Public and Indian Housing
Original is retained by the requesting organization. form HUD-9886 (7/94)ref. Handbooks 7420.7, 7420.8, & 7465.1
Signatures:
__________________________________________________ _______________ 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 for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, 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 of information 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 willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $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, against the 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 information by 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 Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-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 regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or 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 members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.
KODIAK ISLAND HOUSING AUTHORITY 3137 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 report assets 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 annual recertification, and when there is a change in your income.
Changes in income must be reported in writing WITHIN TEN (10) DAYS of your knowing about the change.
FAILURE TO REPORT ASSETS OR INCOME, DELIBERATE MISREPRENSENTATION OF ASSETS OR INCOME, AND/OR FALSIFYING INCOME 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, as required, shall be cause for retroactive rent charges and/or termination of a lease agreement.
DO NOT risk your opportunity to receive housing assistance by failing to disclose your income.
KODIAK ISLAND HOUSING AUTHORITY VERIFICATION FORM
Federal law requires us to verify the income of families applying for admission to federally aided housing projects we manage. We ask your cooperation in supplying information regarding the person named below. Please complete the sections as indicated below, date, sign and return promptly in the envelope enclosed. THANK YOU FOR YOUR ASSISTANCE.
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 and assets. I/We understand that this information will be kept confidential. I/We am/are willing that a photocopy of this authorization 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/
RATE
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 Authority 3137 Mill Bay Rd. Kodiak, AK 99615 Attn: Fax (907) 486-4432 or 486-8723
KODIAK ISLAND HOUSING AUTHORITY 3137 Mill Bay Road, Kodiak, AK 99615 Phone: 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 household size (when a person moves in or out of the unit). I/we understand the rules regarding guests\visitors for current KIHA programs 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 owe any money to another Federal program. I/we certify that, for this previous Federal assistance, I/we did not commit any fraud, 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 currently receiving assistance from KIHA, will be my/our principal residence. I/we will not obtain duplicate Federal housing assistance while I/we am/are in this current program. I/we will not live anywhere else without notifying KIHA immediately in writing. 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 of benefits, or verification of my true circumstances. Cooperation includes attending pre-scheduled meetings and completing and signing needed forms. I/we understand failure or refusal to do so may result in delays, denial of assistance, termination of 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 State criminal law. I/we understand that knowingly supplying false, incomplete, or inaccurate information is grounds for denial of assistance, termination of housing assistance and/or termination of tenancy.
Signature and Date of Household Adults
1.______________________________________________ Date:______________________
2.______________________________________________ Date: ______________________
3.______________________________________________ Date: ______________________
UNEMPLOYMENT INFORMATION BENEFITS RELEASE OF INFORMATION FORM
Federal law requires us to verify the income of families applying for admission to federally aided housing projects we manage. We ask your cooperation in supplying information regarding the person named below. Please complete the sections as indicated below, date, sign and return promptly 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 Bay Road, Kodiak, Alaska 99615 any data from my file relating to the items specified below in addition to, information concerning my work history and Unemployment Insurance Claim as requested. Please state whether or not I am currently receiving Unemployment Compensation Benefits.
Signature: Date:
FOR ADOL USE ONLY - DO NOT WRITE BELOW THIS LINE IN 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
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
Your First Name
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 ________________
KODIAK ISLAND HOUSING AUTHORITY 3137 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 admission in the Federally Assisted Housing Programs we operate, and periodically to re-examine family incomes. To comply with this requirement, we ask your cooperation in supplying the information requested below regarding the referenced individual. This information will 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 assistance will be pending until this information is received.
Sincerely,
Housing Advisor Cc: file I authorize the release of the above requested information: __________________________________ Signature Date
DO NOT COMPLETE UNLESS YOU ARE RECEIVING SOCIAL SECURITY BENEFITS
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 me to:
Kodiak Island Housing Authority ATTENTION: 3137 Mill Bay Road Kodiak Island Housing Authority Kodiak, 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 Subsidized Housing
Please release the following information:
Social Security Number Identifying information(including date and place of birth, parents names)
X Monthly Social Security benefit amount X Monthly Supplemental Security Income Payment amount
Information about benefit/payments I received from ______to_________ Information about Medicare claim/coverage from ________to_________ Medical Records Records from my file(specify) ____________________________________ Other (specify) _________________________________________________
I am the individual to whom the information/record applies or the parent or legal guardian of that person. I know that if I make any representation, which I know is false to obtain information from Social Security Records, I could be punished by fine or imprisonment or both.
Signature: (show signatures, names, and addresses of two people if signed by mark.)
Date:____________________ Relationship:____________________
KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA 99615
Phone 907-486-8111 or FAX 907-486-4332
Date
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 History Amount 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
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:
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.
KODIAK ISLAND HOUSING AUTHORITY 3137 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 assistance sought, 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 at 3137 Mill Bay Road, Kodiak, Alaska 99615. Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.
I, certify, under penalty of perjury 1/ , that, to the best of 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 proof of age 2/; or
I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach INS document(s) evidencing eligible immigration status and signed verification consent form.
Immigration status under §§101(a)(15) or 101(a)(20) of the Immigration and Nationality 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 named on statement above.
HA: Enter INS\SAVE Primary Verification #: Date:
1/ Warning: 18 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than five years, 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 or who 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 of proof 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 permanent residence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by §101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category includes a non-citizen under §§210 or 210A or the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], 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 such mater date as enacted by law, and had continuously maintained residence in the U.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under §249 of the INA (8 U.S.C 1259) [amnesty granted under INA 249].
5/ Refugee, asylum, or conditional entry status under §§207, 208 or 203 of INA. A non-citizen who is lawfully present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the 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 of being 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 an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest 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 of the Attorney General's withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h)) [threat to life or freedom].
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 eligible immigration status (other than for non-citizens age 62 or older and receiving assistance on June 19, 1995), HA must 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, middle initial(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 for Child.
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2programlimits.pdf
3verification.pdf
4itemstobring1.pdf
5itemstobring2.pdf
6ThingsYouShouldKnow1.pdf
7ThingsYouShouldKnow2.pdf