RENTAL INCOME - Absentee Shawnee Tribe Of Oklahoma

ABSENTEE SHAWNEE HOUSING AUTHORITYP.O. Box 425 ▪ 107 North Kimberly ▪ Shawnee, Oklahoma 748020425Phone (405) 2731050 ▪ Fax (405) 2750678MUTUAL HELP/HOME OWNERSHIP: Income Requirements are as follows:Family Minimum Maximum Family Minimum MaximumSize Income Income Size Income Income1 $20,900 $33,400 5 $32,200 $51,5002 $23,800 $38,100 6 $34,600 $55,3003 $26,800 $42,900 7 $37,000 $59,1004 $29,800 $47,700 8 $39,300 $62,900RENTAL INCOME: Annual Income not to exceed as follows:FamilyFamilySize Income Size Income1 $33,400 5 $51,5002 $38,100 6 $55,3003 $42,900 7 $59,1004 $47,700 8 $62,900UPDATED: July 17, 2007

ABSENTEE SHAWNEE HOUSING AUTHORITYCONFLICT OF INTEREST POLICYPURPOSE:The purpose of this Policy is to help IHBG recipients manage those situations where Conflictsof Interest arise within the absentee Shawnee Housing Authority’s housing programsgoverned by the Native American Housing Assistance and SelfDetermination Act(NAHASDA) and to ensure fair and equitable treatment for all eligible participants of thoseprograms.APPLICATION OF REQUIREMENTSThe Conflict of Interest provisions apply to anyone who participates in the IHBG recipient’sdecisionmaking process or who gains inside information with regard to the IHBG assistedactivities. Such individuals are, but are not necessarily limited to: housing staff, housing orTribal Board Members, members of their immediate families, Council Members, members oftheir immediate families and such individual business associates.The requirements prohibit any such individuals from benefiting from their position personally,financially or through the receipt of special benefits other than payment of their salary and/orappropriate administrative expenses. This does not prevent housing staff, Board Members,their family members, Council Members, their family members, and/or business associatesfrom receiving housing benefits for which they qualify as lowincome individuals, if not inviolation of Tribal or State Laws.CONFLICT OF INTERESTA Conflict of Interest may occur when an employee of the Absentee Shawnee HousingAuthority, a Member of the Absentee Shawnee Tribal Council/Board of Commissioners, or animmediate relative of an employee or Absentee Shawnee Tribal Council/Board ofCommissioners is selected to receive assistance through any of the Absentee ShawneeHousing Authority Programs.DEFINITIONS:Immediate family: is defined as a parent, spouse, child, sister, brother, motherinlaw,fatherinlaw, soninlaw, daughterinlaw, brotherinlaw, sisterinlaw, grandparents of theemployee or his/her spouse, and grandchildren of the employee, or “foster” or “step”situations within these relationships.

HUD APPROVAL:If the person receiving assistance is of lowincome and they qualify for eligibility, admissionand occupancy, only public disclosure and HUD notification is required per CFR §1000.30(c).However, HUD approval for an exemption is required when there is a potential conflict ofinterest that would be in violation of §1000.30(b). An example of a situation requiring HUDapproval for an exemption to the Conflict of Interest provision would be housing assistance toa TDHE Council/Board Member whose income is between 80% and 100% of median income.PUBLIC DISCLOSURE:The Absentee Shawnee Housing Authority shall make public disclosure the nature ofassistance to be provided and the specific basis for selection of that person. The disclosureshall be provided to the Office of the Principal Chief, National Council and posted at theentrance of the Housing Division Office. A copy of the disclosure shall be provided to HUDbefore assistance is provided.PREVIOUSLY ADMITTED RECIPIENTS UNDER NAHASDA:Recipients should identify any Conflict of Interest for participants previously admitted underNAHASDA that have not been properly reported. The necessary action should immediatelybe taken to make these conflicts of interest public and report them to the recipient’s areaONAP.REFERENCES:NAHASDA Sections: 201(b), 203(d), 207(b) and 408; 24 CFR 85.36 (a) (3); 24CFR 1000.30, 1000.32, 1000.34 and 1000.36

ABSENTEE SHAWNEE HOUSING AUTHORITYPUBLIC DISCLOSURE NOTICETo:Date:Re:Executive OfficeAbsentee ShawneeHousing Authority__________________________________________StaffBoardCouncil_______________________________________________________________The above has applied and has been determined eligible forservices: The nature and basis of the assistance to be providedas follows:Per 24 CFR 1000.30 a public disclosure must be made inaccordance with the Absentee Shawnee Housing Authority’sConflict of Interest Policy.

ABSENTEE SHAWNEE HOUSING AUTHORITYNotification of Potential or Appearance of Conflict ofInterestTo:From:Date:Re:Southern Plains Office of Native American ProgramsAbsentee Shawnee Housing AuthorityP.O. Box 425Shawnee, OK 748020425______________________________________________________________Per 24 CFR 1000.30 and Absentee Shawnee Housing Authority Conflict of InterestPolicy, this is to notify your office that the above named individual will be providedassistance under the Absentee Shawnee Housing Authority__________________________________Housing Program. This person is related(immediate family) to the “decision making process as follows:□□□ASHA EmployeeCouncil Member/Board MemberOther ___________________________The nature and basis of the assistance to be provided is as follows:______________________________________________________________________________________________________________________________________________________________________Signature________________Date

HOUSING APPLICATIONABSENTEE SHAWNEE HOUSING AUTHORITY(PLEASE USE INK)LIST ALL PERSONS WHO WILL BE LIVING IN THE HOUSEHOLD: (USE ADDITIONAL SHEETS IF NECESSARY)All Spaces Must Be Completed. If The Question Does Not Apply to You, Mark N/A.MARRIED c SINGLEc DIVORCED c SEPARATED c WIDOWED c1.NAME: LAST, FIRST, M.I. RELATION RACE/TRIBE SEX DATE OF BIRTH/PLACE SOCIAL SECURITY #2.3.4.5.6.7.8.9.10.Current Address:_____________________ City: _______________ State: ____ Zip: _________Phone #: _________________ Work #: _______________ Message #: ____________________Present Landlord: _______________________________________Address: __________________Home Phone #: ________________ Work Phone #: ______________ Message #: __________Current Rent Amount: $ __________ Reason for housing need: (Why are you moving?)____________________________________________________________________________________________________________________.Are you or any family member handicapped or disabled? (Optional) ______Certified Disability? ________Wheelchair? _____How many miles do you drive to work each day?_____RENTAL PROGRAMLIST AREA, IN ORDER OF PREFERENCE, IN WHICH YOU WOULD LIKE TO LIVE:1. ____________________________________ 2. _____________________________________Elderly units are located in Shawnee, Wanette and McLoud.Family units are located in Shawnee and Tecumseh only.MUTUAL HELP/HOMEOWNERSHIP PROGRAMLIST AREA, IN ORDER OF PREFERENCE, IN WHICH YOU WOULD LIKE TO LIVE:1. _________________________ 2. _______________________ 3. _____________________

LIST TWO (2) PERSONAL REFERENCES (must not be related):1) Name: ____________________________ Address: ___________________ Zip: _____Phone #: __________________________ How long acquainted? _________________2) Name: ____________________________ Address: ___________________ Zip: _____Phone #: ___________________________ How long acquainted? _________________LIST TWO (2) NEXT OF KIN:1) Name: _____________________________ Address: ___________________ Zip: _____Phone #: ___________________________ Relationship? ________________________2) Name: _____________________________ Address: ___________________ Zip: _____Phone #: ___________________________ Relationship? ________________________List your previous addresses and landlords for the past five years.We must have a telephone number and an address for landlords.Date: From: ___________________________________ To:________________________________Rental Address: __________________________________ Reason for Moving:___________________Landlord Name: __________________________________ Address: ______________ Zip: _________Phone #: _______________________________________ Office Phone #: ______________________Date: From: ___________________________________ To: ________________________________Rental Address: __________________________________ Reason for Moving: ___________________Landlord Name: __________________________________ Address: _______________ Zip: ________Phone #: ________________________________________ Office Phone #: ______________________Date: From: ____________________________________ To: ________________________________Rental Address: ___________________________________ Reason for Moving:___________________Landlord Name: ___________________________________ Address: _______________ Zip: ________Phone #: ________________________________________ Office Phone #: ______________________Income Information:#1 – Head of HouseholdName: ________________________________ Birthday:______________ Social Security #: ____________Relationship: ________________________________ Age: _________________ Sex: __________________Tribal Affiliations: _________________________________________________________________________Income or Assets (check all that apply): Verification of income must be attached.[ ] Student 18 years of older (please state if high school or college/votech):__________________________[ ] Employed (list employer name, address & phone #): __________________________________________[ ] Unemployed (& receiving no assistance or benefits)[ ] Unemployed benefits or workman’s comp. (circle one)[ ] Social Security and/or S.S.I.[ ] TANF (formerly AFDC) or Aid to the Disabled (circle one)[ ] Child Support (please list agency to individual):_______________________________________________[ ] Retirement or pension (please list agency received from): ______________________________________[ ] Other: ________________________________________________________________________________

#2 – SpouseName: _____________________________ Birthday: _______________ Social Security #: ____________Relationship: ____________________________ Age: ____________________ Sex: __________________Tribal Affiliations:__________________________________________________________________________Income or Assets (check all that apply): Verification of income must be attached.[ ] Student 18 years of older (please state if high school or college/votech):__________________________[ ] Employed (list employer name, address & phone #): __________________________________________[ ] Unemployed (& receiving no assistance or benefits)[ ] Unemployed benefits or workman’s comp. (circle one)[ ] Social Security and/or S.S.I.[ ] TANF (formerly AFDC) or Aid to the Disabled (circle one)[ ] Child Support (please list agency to individual): _______________________________________________[ ] Retirement or pension (please list agency received from):_______________________________________[ ] Other: ________________________________________________________________________________#3 – OtherName: ______________________________ Birthday: _______________ Social Security #: ____________Relationship:_____________________________ Age: ____________________ Sex: __________________Tribal Affiliations: _________________________________________________________________________Income or Assets (check all that apply): Verification of income must be attached.[ ] Student 18 years of older (please state if high school or college/votech):__________________________[ ] Employed (list employer name, address & phone #): __________________________________________[ ] Unemployed (& receiving no assistance or benefits)[ ] Unemployed benefits or workman’s comp. (circle one)[ ] Social Security and/or S.S.I.[ ] TANF (formerly AFDC) or Aid to the Disabled (circle one)[ ] Child Support (please list agency to individual): _______________________________________________[ ] Retirement or pension (please list agency received from): ______________________________________[ ] Other: ________________________________________________________________________________If you or your spouse are over 62, disabled, or handicapped, and have medical expenses, pleasesubmit verification for an income adjustment. If you have child care expenses for children 12 andunder, contact our office for proper verification forms.Have you ever filed an application with the Absentee Shawnee Housing Authority before?________When?__________________________________________________________________________Have you ever filed an application with any other Housing Authority? ______If so, which one? ___________________________________ When? ______Have you ever lived in Low Rent Housing before? _______If so, which one? __________________________________ When? ________________________Are you or your spouse currently in a home that is subsidized by the Department of Housing andUrban Development in an ownership capacity? ________________Have you or your spouse ever lived in a Mutual Help Home?: ________If so, which one? __________________________________ When?: _______Have you or any member of your family ever been evicted?If yes, explain the circumstances:

Have you or any member of your family ever owned a home?Are you now buying? Sold Home? Repossessed?Have you or any member of your household ever been arrested?If yes, name the person(s):Crime Committed: Year: County/State:LOCATION AND LAND STATUS (for Mutual Help/Homeownership only)Do you own land? ____ Yes ____ No Number of acres: __________________ County: __________________Legal description (Rural) ___________________ Section __________ Twp _________ Rge ______________Legal description (city) Lot(s) _________________________ Blk _______________Addition ___________Is the land in your name? ____ Yes ____ NoIf no, please give the name of the owner: _____________________________________________________Relationship: ___________________________ Address: ___________________________________________________________________________________________________________________Phone: _____________________________________________________________________Does the Government hold the land in trust? ____Yes ____ NoIf yes, attach the application for gift deed, signed by owners. This can be obtained from the realty departmentat the Bureau of Indian Affairs.Is an abstract on the property available for inspection by our attorney? _____________________________I have answered every question and filled in all the requested information to the best ofmy ability. No fraudulent statements have been made or implied, and I have no objectionto inquiries being made for the purpose of verification of statements made herein. I fullyunderstand that false statements are subject to prosecution and/or rejection of myapplication.By signing this application, I agree to allow a home visit and also to provide anyadditional information requested.I understand that it is my responsibility to update my application at least once a year,and must notify the Absentee Shawnee Housing Authority of any changes of address,income or family composition and to answer any correspondence that the HousingAuthority sends to me and I understand that failure to do so will result in the applicationbecoming inactive._________________________________________Applicant’s Signature_______________________________Date_________________________________________Spouse’s Signature________________________________Date

U.S. Department of Housing and Urban DevelopmentOffice of Inspector GeneralPLEASE READ & SIGNHEAD OF HOUSEHOLD:_________________________________ADULT MEMBER: ______________________________________ADULT MEMBER: ______________________________________DATE____________DATE____________DATE____________Things You Should KnowDon't risk your chances for Federally assisted housing by providing false, incomplete, or inaccurate information on yourapplication forms.PurposeThis is to inform you that there is certain information you must provide when applyingfor assisted housing. There are penalties that apply if you knowingly omit informationor give false information.Penalties forCommitting FraudThe United States Department of Housing and Urban Development (HUD) places ahigh priority on preventing fraud. If your application or recertification forms containfalse or incomplete information, you may be:· Evicted from your apartment or house:· Required to repay all overpaid rental assistance you received:· Fined up to S 10,000:· Imprison ed for up to 5 year s; and/or· Prohibited from receiving future assistance.Your State and local governments may have other laws and penalties as well.Asking QuestionsWhen you meet with the person who is to fill out your application, you should knowwhat is expected of you. If you do not understand something, ask for clarification. Thatperson can answer your question or find out what the answer is.Completing TheApplicationIncomeWhen you answer application question s, you must include the following information:· All sources of money you or an y member of your household receive (wages. Welfarepayments, alimony, social security, pension, etc.):· Any money you receive on behalf of your children (child support, social security forchildren, etc.);

Assets· Income from assets (interest from a savings account, credit union, or certificate ofdeposit: dividends from stock, etc.);· Earnings from second job or par t time job;· Any anticipated in come (such as a bon us or pay raise you expect to receive)· All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc. thatare owned by you an d an y adult member of your family's household who will beliving with you.· Any business or asset you sold in the last 2 year s for less than its full value, such asyour home to your children.· The names of all of the people (adults and children ) who will actually be livingwith you, whether or not they are related to you.Signing theApplication· Do not sign any form unless you have read it, understand it, and are sure everything iscomplete and accurate.· When you sign the application and certification for ms, you are claiming that they arecomplete to the best of your knowledge and belief. You are committing fraud if yousign a form knowing that it contains false or misleading information.· Information you give on your application will be verified by your housing agency. Inaddition, HUD may do computer matches of the income you reportwith various Federal, State, or private agencies to verify that it is correct.RecertificationsYou must provide updated information at least once a year. Some programs require thatyou report any changes in income or family/household composition immediately. Besure to ask when you must recertify. You must report on recertification forms:· All in come changes, such as increases of pay and/or benefits, change or loss of joband/or benefits, etc., for all household members.· Any move in or out of a household member; and,· All assets that you or your household member s own an d an y assets that wassold in the last 2 years for less than its full value.Beware of FraudYou should be aware of the following fraud schemes:· Do not pay an y money to file an application;· Do not pay an y money to move up on the waiting list;· Do not pay for anything not cover ed by your lease;· Get a receipt for an y money you pa y; and,· Get a written explanation if you are required to pay for anything other than rent(such as maintenance charges).Reporting Abuse If you are aware of anyone who has falsified an application, or if anyone triesto persuade you to make false statements, report them to the manager of your complex or your PHA. If that is not possible,then call the local HUD office or the HUD Office of Inspector General (OIG) Hotline at (800) 3473735. You can alsowrite to: HUDOIG HOTLINE, (GFI) 451 Seventh Street, S.W., Washington, DC. 20410.

FEDERAL PRIVACY ACT NOTICEfor theSection 8 Rental Certificate, Rental Voucher, Moderate Rehabilitation, and Public and IndianHousing Programs.PURPOSE:USE:Family income and other information is being collected by the Department of Housingand Urban Development (HUD) to determine an applicant’s eligibility, the recommendedunit size, and the amount the family must pay toward rent and utilities.HUD uses family income and other information to assist in managing and monitoringHUDassisted housing programs; to protect the Government’s financial interest; and toverify the accuracy of the information furnished. HUD or a public housing agency/Indianhousing authority may conduct a computer match to verify the information you provided.This information may be released to Federal, State, and local agencies, when relevant,and to civil, criminal or regulator investigators and prosecutors. However, theinformation will not be otherwise disclosed or released outside of HUD, except aspermitted or required by law.PENALTY:You must provide all information requested by the public housing agency/Indian housingauthority, including all social security numbers you, and all other household membersage six (6) years and older, have and use. Giving the social security numbers of allhousehold members 6 years of age and older is mandatory, and not providing the socialsecurity numbers will affect your eligibility. Failure to provide any of the requestedinformation may result in a delay or rejection of your eligibility approval.AUTHORITY FOR INFORMATION COLLECTION:The following laws authorize the collection of the information by HUD or the publichousing agency/Indian housing authority; the U.S. Housing Act of 1937 (42 U.S.C., 1437et seq.), Title VI of the Civil Rights Acts of 1964, and Title VIII of the Civil Rights Act of1968. The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requiresapplicants and residents to submit the social security numbers of all household membersat lease six (6) years old.I read the Federal Privacy Act Notice on ___________________Date________________________________________Signature of Head of Household________________________________________Signature of Spouse

General AuthorizationI/We hereby authorize Absentee Shawnee Housing Authority and Shawnee CreditAssociation, Inc. to pull the consumer reports listed below for the purpose of renting, leasing,purchasing or home improvements. It is understood that a photocopy of this form will alsoserve as authorization. I further authorize the release of any past or current employmentinformation to be released for the purpose of extending credit or for employment purposes.I understand that if the credit report is for employment purposes, that I will be notified andbe able to obtain a copy of the credit report issued.The information obtained is only to be used in connection with this authorization and Iunderstand that this authorization is only valid for 15 days from the date it is signed.______________________________Applicant (full legal name)________________________________CoApplicant (full legal name)______________________________Applicant Signature________________________________CoApplicant Signature______________________________Social Security Number (REQUIRED)________________________________Social Security Number (REQUIRED)______________________________Date of Birth (REQUIRED)________________________________Date of Birth (REQUIRED)______________________________Address______________________________________________________________City, State Zip Date______________________________Agent, Manager or OwnerThe credit information that will be furnished is in response to an inquiry for the purpose ofevaluating credit risks. The information obtained is from sources deemed reliable, theaccuracy of which Shawnee Credit Association, Inc. does not guarantee. The inquirer hasagreed to indemnify the reporting bureau of any damage arising from misuse of thisinformation, and this report is furnished in reliance upon that indemnity. It must be held instrict confidence and complies with the provision of Public Law 91508. The Fair CreditReporting Act.

AUTHORIZATIONfor Release of InformationCONSENT: I authorize and direct any Federal, State, or local agency, organization, business, orindividual to release to Absentee Shawnee Housing Authority any information or materials needed tocomplete and verify my application for participation, and/or to maintain my continued assistance underthe Section 8, Rental Rehabilitation, LowIncome Public and Indian Housing, and/or other housingassistance programs. I understand and agree that this authorization or the information obtained withits use may be given to and used by the Department of Housing and Urban Development (HUD) inadministering and enforcing program rules and policies.INFORMATION COVERED: I understand that, depending on program policies and requirements,previous or current information regarding me or my household may be needed. Verifications andinquiries that may be requested, include but are not limited to:Identity and Marital Status Employment, Income, and Assets Residences and Rental ActivityMedical or Child Care Allowances Credit and Criminal ActivityI understand that this authorization cannot be used to obtain any information about me that is notpertinent to my eligibility for and continued participation in a housing assistance program.GROUPS OR INDIVIDUALS THAT MAY BE ASKED: The groups or individuals that may be asked torelease the above information (depending on program requirements) include, but are not limited to:Previous Landlords (including Past and Present Employers Veterans AdministrationPublic Housing Agencies) Welfare Agencies Retirement SystemsCourts and Post Offices State Unemployment Agencies Banks and other Financial InstitutionsSchools and Colleges Social Security Administration Credit providers and Credit BureausLaw Enforcement Agencies Medical and Child Care Providers Utility CompaniesSupport and Alimony ProvidersCOMPUTER MATCHING NOTICE AND CONSENT: I understand and agree that HUD or the PublicHousing Authority may conduct computer matching programs to verify the information supplied for myapplication or recertification. If a computer match is done, I understand that I have a right tonotification of any adverse information found and a chance to disprove that information. HUD may inthe course of its duties exchange such automated information with other Federal, State, or localagencies, including but not limited to: State Employment Security Agencies; Department of Defense;Office of Personnel Management; the U.S. Postal Service; the Social Security Agency; and Statewelfare and food stamp agencies.CONDITIONS: I agree that a photocopy of this authorization may be used for the purposes statedabove. This authorization will stay in affect for a year and one month from the date signed.SIGNATURESPRINTED/TYPED NAMEHead of Household: ____________________________Date:________ ___Spouse: ____________________________ Date:________ ___Adult Member: ____________________________ Date:________ ___Adult Member: ____________________________ Date:________ ___Adult Member: ____________________________ Date:________ ___WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements ormisrepresentations to any Department or Agency of the U.S. as to any matter within its jurisdiction.

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)PHA requesting release of information; (Cross out space if none)(Full address, name of contact person, and date)U.S. Department of Housingand Urban DevelopmentOffice of Public and Indian HousingIHA requesting release of information: (Cross out space if none)(Full address, name of contact person, and date)Absentee Shawnee Housing AuthorityP.O. Box 425Shawnee, OK 748020425Authority: 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 verificationof salary and wages from current or previous employers; (2)HUD and the HA to request wage and unemployment compensationclaim 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 abovenamed 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 improperuses 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.Persons who apply for or receive assistance under the followingprograms are required to sign this consent form:PHAowned rental public housingTurnkey III Homeownership OpportunitiesMutual Help Homeownership OpportunitySection 23 and 19(c) leased housingSection 23 Housing Assistance PaymentsHAowned rental Indian housingSection 8 Rental CertificateSection 8 Rental VoucherSection 8 Moderate RehabilitationFailure 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 terminationof 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 receivedduring 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 paymentsof 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 dividends).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.Original is retained by the requesting organization. ref. Handbooks 7420.7, 7420.8, & 7465.1 form HUD9886 (7/94)

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.Signatures:_____________________________________________Head of Household______________Date___________________________________________ __________________________________________________ _______________Social Security Number (if any) of Head of Household Other Family Member over age 18 Date__________________________________________________ _______________ __________________________________________________ _______________Spouse Date 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 Other Family Member over age 18 DatePrivacy 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. 360119). 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 monitoringHUDassisted 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.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.Original is retained by the requesting organization. ref. Handbooks 7420.7, 7420.8, & 7465.1 form HUD9886 (7/94)

DECLARATION OF SECTION 214 STATUSNotice to applicants and tenants: In order to be eligible to receive the housing assistance sought, eachapplicant for, or recipient of, housing assistance must be lawfully within the U.S. Please read theDeclaration statement carefully and sign and return to the Housing Authority’s Admissions Office.Please feel free to consult with an immigration lawyer or other immigration expert of your choosing.I, ___________________________________________, certify under penalty of perjury1/, that to thebest of my knowledge, I am lawfully within the United States because (please check the appropriatebox):[ ] I am a citizen by birth, a naturalized citizen or a national of the UnitedStates; or[ ] I have eligible immigration status and I am 62 years of age or older.Attached evidence of proof of age 2/; or[ ] I have eligible immigration status as checked below( see reverse side of this form for explanation). Attach INS document(s)evidencing eligible immigration status and sign verification consent form.[ ] Immigrant 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, 203 of theINA 5/; or[ ] Parole status under §§212(d)(d) 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___________________DateCheck box on left if signature is of adult residing in the unit who is responsible for child named onstatement above.HA: Enter INS/SAVE Primary Verification #: ___________________________________________Date: _____________________(See reverse side for footnotes and instructions)

1/ Warning: 13 U.S.C. 1001 provides, among other things, that whoever knowingly and willfully makes or usesa document or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within thejurisdiction 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 noncitizens who declare eligible immigration status in one of the followingcategories:2/ Eligible immigration status and 62 years of age or older. For noncitizens 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 June19,1995. 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/ Immigrant status under §§101(a)(15) or 101(a)(20) of INA. A noncitizen lawfully admitted for permanentresidence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, asdefined 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 noncitizen admitted under §§210 or 210Aof the INA (8 U.S.C. 1160 or 1161),(special agricultural worker status), who has been granted lawful temporary resident status.4/ Permanent residents under §249 of INA. A noncitizen who entered the U.S. before January 1, 1972, or suchlater date as enacted by law, and has continuously maintained residence in the U.S. since then, and who is notineligible for citizenship, but who is deemed to be lawfully admitted or 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 noncitizen who is lawfullypresent in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) (refugee status); pursuantto the granting of asylum (which has not been terminated) under 208 of the INA (8 U.S.C. 1158) (asylumstatus); 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 a persecution of fear of persecution on account of race, religion, or politicalopinion or because of being uprooted by catastrophic national calamity (conditional entry status).6/ Parole status under §212(d)(5) of INA. A noncitizen 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 noncitizen who is lawfully present in the U.S. as a resultof the Attorney General’s withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h)) (threat to lifeor freedom).8/ Amnesty under §245A of INA. A noncitizen 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 noncitizens age 62 or older and receiving assistance on June 19, 1995), HA must enter INS/SAVEverification 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 lastname. Place an “X” or “√ “ in the appropriate boxes. Sign and date at bottom of page. Place and “X” or “√ “ in the boxbelow signature if the signature is by the adult residing in the unit who is responsible for Child.







ABSENTEE SHAWNEE HOUSING AUTHORITYP. O. BOX 425 * 107 N. KIMBERLYSHAWNEE, OK 74801PHONE: (405)2731050 FAX: (405)2750678Income VerificationRe: _________________________ SSN: _____________DOB: __________The individual named above is an applicant/tenant for housing assistance which issubsidized through the U.S. Department of Housing and Urban Development. Federalregulations require that in order for the household to be eligible, we must verify thehousehold’s income, expenses and other information using third party written verifications.The information you provide will be used only for the purpose of determining thehousehold’s eligibility for the program and will be held in strict confidence. We arerequired to complete our verification process in a short time period and wouldappreciate your prompt response.This form should be completed and signed by a representative of the employer such as a timekeeper, bookkeeperor accountant. This form CANNOT be completed by the employee.Place of Employment: _________________________________________________Address:___________________________________________________Present Position Title: _________________________________________________Date of Employment: _____________________________Basic Rate of Pay per ( ) Hour ( ) Week ( ) Month:Overtime Rate of Pay (per Hour):Average number of hours worked per week, including overtime:Number of Weeks in Each Pay Period:Gross Earnings Per Pay Period:Medical Insurance Deduction, if applicable (per month)Bonuses, tips, or commissions in addition to regular earnings (per month)Total Gross Earnings in the last twelve months (state time period)From ________________ To__________________Estimated total gross earnings in the next twelve months$__________$______________________________$__________$__________$__________$__________$__________Preparer Signature: __________________________________ Date: ________________Title: _____________________________________ Telephone #: ___________________WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statementsor misrepresentations to any Department or Agency of the U.S. as to any matter within its jurisdiction.

ABSENTEE SHAWNEE HOUSING AUTHORITYP. O. BOX 425 * 107 N. KIMBERLYSHAWNEE, OK 74801PHONE: (405)2731050 FAX: (405)2750678Income VerificationRe: _________________________ SSN: _____________DOB: __________The individual named above is an applicant/tenant for housing assistance which issubsidized through the U.S. Department of Housing and Urban Development. Federalregulations require that in order for the household to be eligible, we must verify thehousehold’s income, expenses and other information using third party written verifications.The information you provide will be used only for the purpose of determining thehousehold’s eligibility for the program and will be held in strict confidence. We arerequired to complete our verification process in a short time period and wouldappreciate your prompt response.This form should be completed and signed by a representative of the employer such as a timekeeper, bookkeeperor accountant. This form CANNOT be completed by the employee.Place of Employment: _________________________________________________Address:___________________________________________________Present Position Title: _________________________________________________Date of Employment: _____________________________Basic Rate of Pay per ( ) Hour ( ) Week ( ) Month:Overtime Rate of Pay (per Hour):Average number of hours worked per week, including overtime:Number of Weeks in Each Pay Period:Gross Earnings Per Pay Period:Medical Insurance Deduction, if applicable (per month)Bonuses, tips, or commissions in addition to regular earnings (per month)Total Gross Earnings in the last twelve months (state time period)From ________________ To__________________Estimated total gross earnings in the next twelve months$__________$______________________________$__________$__________$__________$__________$__________Preparer Signature: __________________________________ Date: ________________Title: _____________________________________ Telephone #: ___________________WARNING: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statementsor misrepresentations to any Department or Agency of the U.S. as to any matter its jurisdiction.

RENTAL INCOME - Absentee Shawnee Tribe Of Oklahoma

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