LOW-INCOME RENTAL APPLICATION

Tribal code

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The Bad River Housing Authority has low-rental units. Rent is based on annual adjusted income.

There is a waiting list for all of our housing sites. Timeliness of selection depends on the availability

of housing. Unfortunately, we are unable to offer emergency housing.

We require that you update your application every (12) months. If there are changes in address,

income or family composition it must be reported immediately. The application will be filed inactive

and removed from the waiting list if it is not updated.

The application must be completed before it will be considered for selection. All questions must be

answered. The application must be turned in to the Housing Office seven days prior to Selection

Meeting in order for it to be considered.

Items that you need to complete your application:

•

Social Security cards for all family members.

Updated Tribal cards for all Tribal Members.

Earned income information: such as W2’s, Check stubs and or wage statements.

Unearned income information: such as Child Support, FIP, Social Security, Per Cap and ECT.

Driver’s License/State ID for all family members eighteen years of age or older.

Completed and signed release of information Agreement. A criminal background check will

be completed on all applicants and family members eighteen years of age or older.

Two landlord references from your most recent landlords. If you have ever rented from a

HUD subsidized program, a reference from them must be provided.

If you have never rented or can only supply one Landlord Reference, (Two) personal

References from Professional people such as Social Workers, Case Workers, Teachers,

Counselors, ECT, must be submitted. Personal References will not be accepted if you have

rented in the past. References must be in written form.

When a unit becomes available, the Board of Commissioners reviews the completed applications for

that bedroom size and site. Tenant selection is based on the following criteria:

•

Income Eligibility

The need for housing

Tribal Membership

Native American Heritage

Satisfactory Criminal background Check

Acceptable Landlord References

All situations being equal on the application, the date and time of application will be the

deciding factor.

If you have any questions or need help completing the application you can contact the Housing

Office @ (715) 682-2271. Return your application to the Housing Authority @ P.O. Box 57 Odanah,

Wisconsin 54861.

RENTAL APPLICATION

Received by_______________

PLEASE PRINT CLEARLY

Date _______________

Time _______________

Applicant Name____________________________________________________________________

Current

Address___________________________________________________________________________

City, State, Zip Code________________________________________________________________

Home Phone Number________________________ Work Phone Number______________________

Place of Employment________________________________________________________________

Co Applicant Name_________________________________________________________________

Current Address____________________________________________________________________

City, State, Zip Code________________________________________________________________

Home Phone Number_______________________ Work Phone Number_______________________

Place of Employment________________________________________________________________

Household composition: List the Head of Household first and all other members who will reside in

the home.

Member

Name

Relationship

Date of

Birth

Sex

Social

Security Number

Tribal

Affiliation

_________________________________________________________________________________

Is there an absent parent? If yes, please give the absent parent(s) name and address:

_________________________________________________________________________________

Do you expect the absent parent to live in the home? If yes, when? ___________________________

Will all household members reside in the home year round? _________________________________

Do you anticipate any changes in the household within the next year? _________________________

How long have you lived at your current address? ________________________________________

Why are you looking for housing with the Bad River Housing Authority? _____________________

_________________________________________________________________________________

How many adults live in the home now? _____________________ How many children? ________

Are you or have you ever been evicted? ________________________________________________

If yes, please explain in detail. ________________________________________________________

_________________________________________________________________________________

If yes, you must provide a copy of the eviction notice.

What is your current monthly rent amount? ____________________________________________

What are your monthly costs for all utilities except cable and telephone? ______________________

Name and address of Utility companies:

Electric______________________________________________________________________

Gas_________________________________________________________________________

Water & Sewer _______________________________________________________________

Are you now or have you ever lived in government-subsidized housing? ______________________

If yes, when and where______________________________________________________________

What is your current housing condition? Please explain in detail.

_________________________________________________________________________________

Please list your previous address for the past five (5) years starting with your most current.

1. ____________________________________________ From: ________ To: ________

2. ____________________________________________ From: ________ To: ________

3. ____________________________________________ From: ________ To: ________

4. ____________________________________________ From: ________ To: ________

5. ____________________________________________ From: ________ To: ________

List Names, Address and Phone Number of two relatives or friends who generally know how to

contact you:

Name:

Relationship:

Name:

Relationship:

Address:

Phone:

Address:

Phone:

Do you own a car? _________________________________________________________________

1. Make: ___________ Year: __________

2. Make: ___________ Year: __________

For each type of income that your household receives, give the source of the income and the

amount of income that can be expected from this source during the next twelve (12) months.

Members Name

Source of Income and type

Monthly Amount

_________________________________________________________________________________

Has any household member ever been convicted of any crime other than traffic violations? ________

If yes, who? _____________________________. When? __________ Where? _________________

Are you or your spouse a veteran? _____________________________________________________

What branch of services? ________________________ Service Date? ________________________

Please provide a copy of discharge papers.

Do you or any household member have any current legal proceedings pending? _________________

If yes, please explain: _______________________________________________________________

_________________________________________________________________________________

Has any household member ever used any name(s) or Social Security number other that the one

currently being used? If yes, who and what name? This would include maiden or a name from a

previous marriage. __________________________________________________________________

Please answer “yes” or “no” to each of the following questions.

For each “yes” answer provide details.

Applicant

Co-Applicant

1. Is any member of your household employed full time,

part time or seasonally?

2. Does any member of your household work for someone who

Pays them cash or is self employed?

___________________________

3. Does any member of your household receive regular pay from

from the armed forces?

___________________________

4. Does any member of your household receive workers compensation? ___________________________

5. Does any member of your household expect to work

for any period during the next twelve months?

6. Is any member of your household on leave of absence

from work due to lay off, medical, maternity or military leave?

7. Does any member of your household now receive, or

expect to receive unemployment benefits or severance pay?

8. Does any member of your household receive child support?

(NOTE you must answer this question yes if you have a court

order even if you are not receiving the full amount awarded)

9. Does any member of your household receive alimony/spousal

maintenance?

___________________________

10. Does any member of your household now receive or

Expect the receive welfare assistance or general assistance?

11. Does any member of your household receive or

Expect to receive Social Security Benefits?

(Including unearned income of minor children)

12. Does any member of your household receive disability benefits

including social security disability?

___________________________

13. Does any member of your household receive regular payments

from retirement benefits?

___________________________

14. Does any member of your household receive payments from

Death Benefits?

___________________________

15. Does any member of your household receive regular payments

From inheritance, insurance settlement, lottery winnings ect?

___________________________

16. Does any member of your household receive payments from

Tribal per caps?

___________________________

17. Does any member of your household receive or

expect to receive income from a pension, life insurance dividends

or annuity?

18. Does any member of your household now receive regular cash

contributions from individuals not living in the unit or from agencies?

19. Does any member of your household receive income form assets

including interest in checking or saving accounts, interest and

dividends from certificates of deposit, stocks or bonds, or income

from rental property?

20. Do you or any member own a home or other

Real estate?

If yes, what is the market value of the home/real estate?

21. Have you or any member of your household

sold or given away real property or other assets

in the past two (2) years?

If yes, what was the market value?

HOUSEHOLD ASSET INFORMATION

Program regulations require that all assets be disclosed in order to determine qualification. Does any

household member including minor children have money held in the following?

YES

CURRENT BALANCE

____ ____ Checking accounts (6month average balance) ………………...$__________________

____

____ Savings accounts…………………………………………… $ __________________

____

____ Stocks……………………………………………………….

____

____ Capital Investment………………………………………….. $__________________

____

____ Bonds ……………………………………………………….. $__________________

____

____ Trusts………………………………………………………… $__________________

____

____ Securities…………………………………...……………….

____

____ Whole life insurance policy (do not include term life)...….... $__________________

____

____ 401K…..…………………………………………………….. $__________________

____

____ IRA/KEOGH Accounts ...…………………………………… $__________________

____

____ Certificate of deposit………………………………………… $__________________

____

____ Pension/retirement/annuity accounts ……...……………….

____

____ Money market funds …………………………………..….... $__________________

____

____ Treasury bills.……………………………………………….. $__________________

____

____ Safety deposit box……….…………………………………… $__________________

____

____ Lump sum payment (inheritance, insurance settlement,

$__________________

lottery winnings, capital gains...………………………..….... $__________________

____

____ Are any accounts jointly held with someone not in the unit… $__________________

Which accounts? ________________ and with whom______________________

____

____ Other……………………..…………………………………… $__________________

**Include trusts, 401K, ect. Only if accounts are accessible to the household prior to the termination of

employment, retirement or death. If you are unsure, list the account, and it will be verified**

If you have additional information that you would like to add to your application, please use an

additional sheet.

I understand the information given on this application will be held in confidence and will be used for

the sole purpose of determining my eligibility and suitability for housing programs. I understand that

this is not a contract and does not bind either party. The above information is full, true and complete

to the best of my knowledge. I understand that my selection for Housing may be contingent upon the

Housing being able to formally verify this information. I understand that any falsification,

misrepresentation or concealment of information by me can result in my eviction from any dwelling

obtained from the Housing Authority and possible prosecution under the law. I have no objections to

inquires being made for the purpose of verifying the statements made herein.

WARNING: Section 1001 of Title 18 of the U.S. code makes it a criminal offense to make

willful false statements or misrepresentation to any department or agency of the United States

as to any matter within its jurisdiction.

APPLICATION CERTIFICATION

GIVING TRUE AND COMPLETE INFORMATION

I certify that all information provided on household composition, income, family assets and items for

allowances and deductions, is accurate and complete to best of my knowledge. I have reviewed the

application form and certify that the information shown is true and correct.

REPORTING CHANGES IN INCOME OR HOUSEHOLD COMPOSITION

I certify that I have disclosed where I received any previous Federal housing assistance and whether

or not any money is owed. I certify that for this previous assistance I did not commit any fraud,

knowingly misrepresent any information, or vacate the unit in violation of the lease.

NO DUPLICATE RESIDENCE OR ASSISTANCE

I certify that the house or apartment will be my principal residence and that I will not obtain

duplicated Federal housing assistance while I am in this current program. I will not live anywhere

else without notifying the Housing immediately in writing. I will not sublease my assisted residence.

COOPERATION

I know I am to cooperate in supplying all information needed to determine my eligibility level of

benefits, or verify my true circumstances. Cooperation includes attending pre-scheduled meeting and

completing and signing needed forms. I understand failure or refusal to do so may result in delays or

termination of assistance and/or eviction.

CRIMINAL AND ADMINISTRATIVE ACTIONS FOR FALSE INFORAMTION

I understand that knowingly supplying false, incomplete or inaccurate information is punishable

under Federal or State criminal law. I understand that knowingly supplying false, incomplete, or

inaccurate information is grounds for termination of housing assistance and/or termination of

tenancy.

Applicant Signature

________________________________

Date ___________________

Co-Applicant Signature ________________________________

Date ___________________

RELEASE OF INFORMATION

Bad River Housing Authority

P.O. Box 57

Odanah, Wisconsin 54861

715-682-2271 Fax: 715-682-6818

AGREEMENT

DO NOT ALTER THIS DOCUMENT: Failing to sign this form in its original condition could

jeopardize your eligibility for housing assistance.

Personal Information

Name: Last:

Middle:

First:

Maiden:

Social Security Number:

Date of Birth:

Driver’s License #:

State Issued:

Address:

City, State, Zip Code:

I herby authorize confidential information to be released between the agencies listed in this

agreement.

AGENCIES RELEASING INFORMATION TO EACH OTHER

Bad River Housing Authority

P.O. Box 57

Odanah, Wisconsin 54861

School and Colleges

Support and Alimony Providers

Child Care Providers

Retirement Systems

Courts and Post Offices

Current Employers

Previous Employers

Social Security Administration

Tribal Social Services

Utility Companies

Law Enforcement Agencies

Credit Providers/Bureaus

Current and Previous Landlords

Family Independence Agency

Applicant /Client Signature ______________________________

Date

Co Applicant Client Signature____________________________

Date

LANDLORD REFERENCE QUESTIONNAIRE

__________________________________________

Current or Previous Landlord

__________________________________________

Date:___________________________

__________________________________________

Address

__________________________________________

of rental:________________________

RE: ____________________________

Dear Sir or Madam:

We are asking for your cooperation in supplying information on the tenant history on the family

listed above. This information will only be used only in determining whether the family can be

accepted for admission to our program. Your prompt return will be appreciated. If you have any

questions, please call me at (715) 682-2271

Thank You,

Housing Representative

I hereby authorize the release of the information requested below.

_________________________________________

Signature of Applicant

Circle one: Current Landlord – Previous Landlord – Other

Is this a subsidized unit? _____________________________________________________________

Date of applicant’s tenancy: From: _____________________

To: _________________________

Are you a friend or relative? Friend_____ Relative_____ No_____

RENTAL PAYMENT

Monthly rent amount?

Is (was) applicant current on rent?

If no, please explain:________________________________________________

Have you ever begun eviction proceedings for nonpayment?

Does this applicant still owe money?

How Much?

CARING FOR THE UNIT

Does (did) the applicant keep the unit clean? _______________________________________

Has (had) the applicant damaged the unit?_________________________________________

If so, please describe: _________________________________________________________

How expensive: ___________________________

How often: ______________________

Has (had) the applicant paid for the damages?_______________________________________

Will you (did you) keep any of the security deposit? _________________________________

Did (does) the applicant have pets?____________________ How many?______________________

GENERAL

Does (did) the applicant permit persons other than those authorized to live in the unit?____________

Please describe:________________________________________________

Are you aware of any problems such as abuse and/or domestic violence? ______________________

Please describe : _______________________________________________

Does the applicant interfere with the rights and quiet enjoyment of other residents?_______________

Please describe: _____________________________________________________________

Were the police ever called because of a disturbance?

Has the applicant given you any false information?

Please describe: _____________________________________________________________

Would you rent to this family again?

If not, why?

_________________________________________________________________________________

What was the family’s reason for moving? ______________________________________________

What previous address did the applicant give when they applied for housing? ___________________

_________________________________________________________________________________

What forwarding address did the applicant give when they moved? ___________________________

_________________________________________________________________________________

____________________________________

_______________________________

Signature of Landlord or Agent

Date

Daytime Phone Number: ____________________________________

To be completed by the Housing Staff

Verified? Yes _____

No _____

Name of person supplying information

______________________________________________

Additional Comments, Concerns and Notations:

Signature of Housing Staff, verifying reference and date

DRUG FREE HOUSEHOLD STATEMENT

I, the undersigned, do hereby attest that myself and all members of my household do not use any

illegal drug(s).

I further attest that myself and all members of my household are not involved in selling, possession,

or use of any illegal drug, and that my household is a drug free household.

I further understand that if myself, members of my household, or guest(s) of my household use, sell

or are in possession of illegal drug(s), that I am subject to immediate eviction.

I understand that this statement will remain in effect for the entire length of my tenancy with the Bad

River Housing Authority.

ALL PERSONS 18 AND OVER SHALL SIGN THIS STATEMENT

______________________________________________________

Signature

________________________

Date

______________________________________________________

Signature

________________________

Date

______________________________________________________

Signature

________________________

Date

______________________________________________________

Signature

_________________________

Date

______________________________________________________

Signature

_________________________

Date

Authorization for the Release of Information /

Privacy Act Notice

U.S. Department of Housing

and Urban Development

Office of Public and Indian Housing

To the U.S. Department of Housing and Urban development (HUD)

And the Housing Agency/Authority (HA)

PHA requesting release of information; (Cross our space if none)

(Full address, name of contact person, and date)

IHA requesting release of information (Cross out space if none)

(Full address, name of contact person and date)

Bad River Housing Authority

P.O. Box 57

Odanah, Wisconsin 54861

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 verifycation of salary and wages from current or previous employers; (2)

HUD and the HA to request wage and unemployment compensaTion claim information; (3) HUD to request certain tax return

information form the state agency responsible for keeping that

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 this 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.522a. HUD may disclose information

(other than tax return information) for certain routine uses, such as

to government agencies for law enforcement purposes and to HA’s

for the purpose of determining housing assistance. The HA is also

required to protect the income information it obtains in accordance

with any applicable State privacy law. HUD and HA employees

may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the

consent form. Private owners may not request or receive

information authorized by this form.

Who Must Sign the Consent Form: Each member of your

household who is 18 years of age or older must sign the consent

form. Additional signatures must be obtained from new adult

members joining the household or whenever members of the

household becomes 18 years of age.

Original is retained by the requesting organization

Persons who apply for or receive assistance under the following

programs are required to sign this consent form:

PHA-owed rental public housing

Turnkey III Homeownership Opportunities

Mutual Help Homeownership Opportunity

Section 23 Housing Assistance Payments

HA-owned rental Indian housing

Section 8 Rental Certificate

Section 8 Rental Voucher

Section 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consent

Form may result in the denial of eligibility or termination of

Assisted housing benefits, or both. Denial of eligibility or termiNation of benefits is subject to the HA’s grievance procedures

and Section 8 informal hearing procedures.

Sources of Information To Be Obtained

State Wage Information Collection Agencies. (This consent is

Limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have

received assisted housing benefits)

U.S. Social Security Administration (HUD only) (This consent is

limited to the wage and self employment information and

payments of retirement income as referenced at Section 6103

(1)(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 used to obtained directly from: (a)

current and former employers concerning salary and wages and

(b) financial institutions concerning unearned income (i.e,

interest and dividends). I understand that income information

obtained from these sources will be used to verify information

that I provided 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.

Ref. Handbooks 7420.7, 7420.8 & 7465.1

Form HUD-9886 (7/94)

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 HA’s that receive income

information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying that the

amount was, whether I actually has access to the funds and when the funds were received. In addition, I must be given an opportunity to

consent those determinations.

This consent form expires 15 months after signed.

Signatures:

_____________________________________ __________

Head of Household

Date