# LOW-INCOME RENTAL APPLICATION > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Abad_river_chippewa%3Aff6828bdcc37fbe4 ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text LOW-INCOME RENTAL APPLICATION 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 NO 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 and 19© 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 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 Other Family Member over age 18 Date Social Security Number (if any) Head of Household _____________________________________ _________ 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 Date ______________________________________ Other Family Member over age 18 ______ ___ Date 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. 20000d), 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 collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay towards rent and utilities. Other Uses: JUD 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 an 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. Penalties for Missing this Contest: HUD and HA and any owner (or any employee of HUD 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 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 apporp[eraire, against the 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 HUD-9886 (7/94 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Abad_river_chippewa%3Aff6828bdcc37fbe4. Public record. Not legal advice.