Documentation REQUIRED to Apply:

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IDC

Housing Assistance

Application

Documentation REQUIRED to Apply:

All Adults Over 18 in the Household:

• Tribal ID, if applicable

• Driver’s license or state issued ID

• Social Security card

• If employed: 4-6 pay stubs or letter from your employer stating your pay rate and an average amount of

hours you work every week, on company letterhead or notarized

• If unemployed: unemployment benefit letter (even if you don't qualify for unemployment benefits) and

Affidavit of Unemployment

• Social Security or Supplemental Security Income: benefit letter

• Most recent Federal tax return, or Affidavit for Non-filing tax return

• TANF, if applicable

• Per capita payments/Tribal General Assistance, if applicable

• Print out of Checking Account or Affidavit of No Bank Account

• Print out of Saving Account or Affidavit of No Bank Account

• Copy of additional saving account, such as 401k or IRA, if applicable

• Marriage license or notarized statement of what constitutes you as a family (unmarried couples), if

applicable

All Children in the Household:

• Tribal ID, if applicable

• Social Security card

• Birth Certificate

• Proof of custody, if applicable

• Copy of child support orders or signed and notarized Child Support Affidavit

Exhibit 3

Page 1

ISWA Housing Development Corporation

Housing Assistance Application

Date ____/____/____

HOUSING PROGRAMS:

Check the program(s) you are applying for.

Check this box if you are interested in

applying for a yearly leased rental

dwelling unit.

Rental Housing Program

Check this box if you are interested in Emergency

Housing.

Emergency Housing

APPLICANT INFORMATION:

Applicant’s Name

(Last)

Present Street

Address

(First)

(Middle)

No. of Years

(Street Address)

Own Rent

(City)

(State)

(Zip Code)

Contact Information

(Phone Number)

Previous Street

Address

(Email Address)

No. of Years

(Street Address)

Own Rent

(City)

Marital Status

Number of

Dependents

Are you unemployed?

Married

Separated

(Zip Code)

Unmarried (including single, divorced, widowed)

Ages of

Dependents

If yes, please explain why you are unemployed.

Name of Employer

(Business Phone No.)

(State)

Yes

Address of

Employer

(Applicant’s Position/Title)

(Type of Business)

No. of years on

job

Are you selfemployed?

Yes No

Yrs. In this line

of work

Employer’s fax # and/or email address:

Are you or anyone in the household related to any ISWA employee’s? If so, list their name and your

relation:

Are you a full-time student? If yes, what school do you attend?

Yes

If you are applying for Emergency Housing, do you have proof of being a burnout victim, victim of

domestic violence, or homeless? If no, you will not be eligible for emergency housing.

Co-Applicant’s Name

(if applicable)

Present Street Address

(Last)

(First)

Yes

N/A

(Middle)

No. of Years

(Street Address)

Own Rent

(City)

(State)

Previous Street

Address

(Zip Code)

No. of Years

(Street Address)

Own Rent

(City)

(State)

(Zip Code)

Contact Information

(Phone Number)

Marital Status

Number of

Dependents

Are you unemployed?

Married

Separated

(Email Address)

Unmarried (including single, divorced, widowed)

Ages of

Dependents

If yes, please explain why you are unemployed.

Name of Employer

(Business Phone No.)

Yes

Address of

Employer

(Co-Applicant’s Position/Title)

(Type of Business)

No. of years on

job

Are you selfemployed?

Yes No

Yrs. in this line

of work

Employer’s fax # and/or email address:

Are you a full-time student? If yes, what school do you attend?

Are you or anyone in the household related to any ISWA employee’s? If so, list their name and your

relation:

If you are applying for Emergency Housing, do you have proof of being a burnout victim, victim of

domestic violence, or homeless? If no, you will not be eligible for emergency housing.

10)

Yes No

N/A

HOUSEHOLD COMPOSITION: List the head of household first. Then list each member who will be residing

in the home. Give the relationship of each family member to the head of household.

Full Name

Yes

(Head of Household)

Relationship

Age

DOB

Social Security Number

Does anyone live with you who are not listed on the previous page?

Yes

Does anyone plan to live with you in the future who are not listed on the previous page?

Yes

Please explain if you answer “yes” to either question above.

__________________________________________________________________________________________

INCOME:

SOURCE

How much annual income is your household receiving?

Applicant

Co-Applicant

Salary

Overtime Pay

Commissions

Fees

Tips

Bonuses

Interest and/or

Dividends

Net Income

from Business

Net Rental

Income

Social Security,

Pensions,

Retirement

Funds, Etc.

(Received

Periodically)

Unemployment

Benefits

Workers

Compensation,

Etc.

Child Support

Alimony

Public

Assistance

Other

ASSETS

TYPE

Checking

Account(s)

Savings

Account(s)

Credit Union

Account(s)

Life Insurance

Stocks

Other

Other Household

Members 18 & Older

TOTAL

TOTALS

BANK NAME

ACCOUNT NUMBER

CASH VALUE

INCOME FROM ASSETS

Have you disposed of any assets in the last 24 months?

Yes

If yes, please list any assets disposed of: __________________________________________________________

HOME OWNERSHIP STATUS:

Check the one that applies to you.

I currently own my own home free and clear.

I currently am buying my home and have a

mortgage to pay off.

I currently lease with an option to buy the

home I reside in.

I currently rent the home I reside in.

I have a land assignment.

Other (please explain)

Type of Residence:

Check the one that applies to you.

My current residence is a single-family home.

My current residence is a duplex.

My current residence is an apartment.

My current residence is a mobile home.

Other (please explain)

_________________________________________

Are your property taxes paid and up to date (if applicable)?

Yes

Which agency do you have Homeowner’s Insurance with (if applicable)?

10)

LIABILITIES: List outstanding obligations (your debts) including auto loans, credit cards, charge accounts,

Credit union loans, personal loans, medical expenses, real estate loans except for the home you live in and any

other loans.

TYPE

CREDITOR’S NAME

MONTHLY

UNPAID BALANCE

DUE DATE

PAYMENT

__________________________

Do you have any outstanding unpaid judgments?

Yes

In the last 7 years, have you declared bankruptcy?

Yes

Are you a party in a lawsuit?

Yes

If yes, to any of the above, please explain: _____________________________________________________

__________________________________________________________________________________________

11)

MONTHLY HOUSING EXPENSE:

Mortgage (Monthly)

Property Insurance (Yearly)

Property Taxes (Yearly)

Rent if not buying home

(Monthly)

Utility Costs (Monthly)

Child Care (Monthly)

Other

Describe any special circumstances relative

to your housing or its financing:

____________________________________

I/We certify that all the statements on this ISWA Development Corporation Housing Assistance Application are true

and correct to the best of my/our knowledge.

I/We understand that funds are limited and that ISWA Development Corporation cannot guarantee that financial

assistance will always be available.

I/We understand that completion of the Homebuyer’s Educational Program offered by the ISWA Development

Corporation is required when participating in Housing Assistance Programs before the disbursement of any funds and

is not a guarantee that financial assistance will be provided.

Privacy Act Notice: This information is to be used by the ISWA Development Corporation in determining whether you

qualify for assistance under its programs. It will not be disclosed outside the agency except as required and permitted

by law. You do not have to provide this information, but if you do not, your application for approval of assistance

may be rejected.

12)

Applicant:

________________________________________

_________________________

13)

Co-Applicant:

________________________________________

_________________________

Signature

Date

~~~~~~~~~~~~~~~~~~~~~FOR OFFICE USE ONLY~~~~~~~~~~~~~~~~~~~~

Received By:

Client #:

Reviewed By:

Date Received:

Approved By:

# of People in Household/# of Bedrooms:

Comments:

Verified Income:

Min.

30%

80%

No. in Family

Minimum Allowable

Income

30% Median Income

$16,830

$19,210

$21,633

$24,013

$27,600

$31,612

$35,624

$39,636

$19,800

$22,600

$25,450

$28,250

$32,470

$37,190

$41,910

$46,630

*income guidelines updated 07/01/2022

Maximum Allowable

Income 80% Median

Income

$52,750

$60,300

$67,850

$75,350

$81,400

$87,450

$93,450

$99,500

100% Median Income

$66,000

$75,400

$84,800

$94,200

$101,800

$109,300

$116,900

$124,400

AUTHORITY TO VERIFY INFORMATION

This is your authority to verify my accounts, employment, outstanding debts, including

any present or previous mortgages, to order a consumer credit report, criminal

background checks and to make any other inquires pertaining to my qualifications for

assistance from ISWA Development Corporation. Copies of this letter may be made for

Distribution to any party with which I have a financial or credit relationship and that

party may treat such copy as an original.

PRIVACY ACT NOTICE: This information is to be used by ISWA Development Corporation in determining whether you

qualify for assistance under its programs. It will not be disclosed outside the agency except as required and permitted

by law. This documentation will remain in effect for one year from the date signed. You do not have to provide this

information, but if you do not your application for approval of assistance may be rejected.

Any household member over the age of 18 needs to sign below:

________________________________________

(Applicant’s Printed Name)

(Applicant’s Signature)

(Co-Applicant’s Printed Name)

(Co-Applicant’s Signature)

(Co-Applicant’s Printed Name)

(Co-Applicant’s Signature)

(Co-Applicant’s Printed Name)

(Co-Applicant’s Signature)

________________________________________

Today’s date

(Date of Birth)

(Social Security Number)

(Date of Birth)

(Social Security Number)

(Date of Birth)

(Social Security Number)

(Date of Birth)

(Social Security Number)

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.