Housing Application Step 1 of 7 14% Name(Required) First Last Maiden Name Other Names Previously Applied Under Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Email(Required) Phone(Required) About Your FamilyFamily Composition Name Relation to Head Date of Birth Place of Birth Sex (M/F) Actions Edit Delete There are no Family Members. Add Family Member Maximum number of family members reached. Income InformationIncome RecordPlease list all income each household member receives over the age of 18. All income must be reported for eligibility purposes. Any false or deliberate omission of information provided by the applicant that materially affects eligibility will be grounds for denial of this application. If a family member is receiving social security benefits, please fill out and sign the Social Security Administration Consent for Release of Information form for all members receiving benefit. Household Member Name Name & Address of Employer or Source of Income Employer Annual Wage Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Other Income Household Member Name Source of Retirement/Annuities of Other Income Phone/Fax of Retirement Source Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Do you or any of your household receive any of the following types of income or assistance?If any household members receive any of these types of income or assistance, we will request copies of statements from all agencies showing amounts and the name of the recipient. Public Assistance Social Security Unemployment Child Support Longevity VA Benefits Other Type of Benefit(s) Received(Required) Describe Other(Required) AssetsPlease list the type and value of your assets IF OVER $5,000Enter Assets Asset Type Value Descibe Other Actions Edit Delete There are no Assets. Add Asset Maximum number of assets reached. Basic QuestionaireHave you ever applied for any NIHA program?(Required) Yes No Name on Application(Required) Date(Required) MM slash DD slash YYYY Have you ever participated in a federally funded housing program?(Required) Yes No Location/Program(Required) Date(Required) MM slash DD slash YYYY Are you presently on a waiting list for a federally funded program?(Required) Yes No Location/Program(Required) Date(Required) MM slash DD slash YYYY Have you ever subleased a federally funded unit?(Required) Yes No Location/Program(Required) Date(Required) MM slash DD slash YYYY Do you currently owe any money to any Housing Authority or HUD?(Required) Yes No Location/Program(Required) Date(Required) MM slash DD slash YYYY Have you or any member of your household been charged or convicted of any criminal offenses?(Required) Yes No Please Explain(Required) List your last two (2) landlords and villages you lived inLandlord(Required) Village(Required) Landlord(Required) Village(Required) Disclaimer ANY FALSE INFORMATION OR DELIBERATE OMISSION OF INFORMATION PROVIDED BY THE APPLICANT THAT MATERIALLY AFFECTS ELIGIBILITY WILL BE GROUNDS FOR DENIAL OF THE APPLICATION OR TERMINATION FROM THE PROGRAM For Local Vendor and Utilities Credit Verifications(Required) I consent to allow the NW Inupiat Housing Authority to request and obtain credit information from the local (Alaska) Vendor or Utility listed on this form for the purpose of verifying my eligibility and level of benefits under HUD’s assisted housing programs. I understand that the credit information received by the NW Inupiat Housing Authority under this consent form cannot use it to deny, reduce, or terminate assistance without first independently verifying what the amount was. I, then, must be given the opportunity to contest any determinations. Name of Vendor/Utility(Required) 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 USC 3601-19). The Housing and Community Development Act of 1987 (42 USC. 3543) requires applications 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, have and use. Giving the Social Security Numbers of all household members 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. Northwest Inupiat Housing AuthorityP.O. Box 331Kotzebue, AK 99752(907) 442-3450Verification of Understanding(Required) I have read and understand the application and Federal Privacy Act Notice, along with this consent form. This consent expires fifteen (15) months after signed. Digital Signature(Required)By typing your name electronically, you are agreeing that your electronic signature is the legal equivalent of your manual signature on this application. 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 9836. Any person who knowingly or willfully requests, obtains or disclosures any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.00. 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.