Delaware Nation Housing

Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

Housing Assistance Application Check Sheet

In order to determine eligibility, the following items are required for all household members:

[ ] Completed Application (including all verifying Documentation)

[ ] Degree of Indian Blood-copy of CDIB card; copy of BIA enrollment card; or copy of

tribal enrollment letter of all Native American members.

[ ] Verification of all Anticipated Income Sources, including Employment (12 Months),

Social Security, Public Assistance/Welfare, Land Leases/ Oil and Gas Royalties,

Retirements/Disability Benefits, Child Support/ Alimony, Unemployment Benefits,

and etc. All members 18 and older must provide an “Information Release

Authorization” for BIA accounts and land holdings and income verifications.

[ ] Copy of Property Deed Title (Proof of Ownership). Rental and Multiple or Jointly

Owned Property will require additional forms, please request.

[ ] Copy of Marriage Certificate

[ ] Copy of Divorce Decree or Legal Separation

[ ] Notarized Affidavit of Common-Law Marriage Acknowledgment

[ ] Verification of Child Care Services

[ ] Verification of Medical Deductions

[ ] Verification of Higher Education Grants

[ ] Copy of Social Security Card(s) for each Family Member

[ ] Copy of Original Birth Certificate(s) for each Family Member

[ ] Other forms that need to be signed and filled out: Authorization for the Release of

Public Information, Federal Privacy Act and Employment Verification Form

[ ] Other:

Please review this list and make sure that you have provided all requested information for your application to be

complete. If this information is not provided, the resident services department will not be able to determine your

tentative eligibility, and your application will be considered ineligible.

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Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

Please indicate for which you are applying: Lease-Purchase _______

Low Rent _______

HOUSING ASSISTANCE APPLICATION

The following are requirements when applying for the Homebuyer and Low Rent Program:

 You must update your application every year to remain on the lease purchase Housing Department waiting list.

 You must qualify as a family and all admission requirements listed in policies.

 You must sign a lease agreement.

 You will be responsible for all maintenance on home (Homebuyers).

 You will be responsible for keeping the home safe, drug free & sanitary at all times.

 You must keep your utility services accounts paid for at all times.

 You will be responsible for making your house payments promptly on the first but no later than the

fifth day of each month.

 You may have your home inspected every year by Housing Department inspectors.

 You may not exceed the HUD income limits as shown in the table below.

2026 Median Family Income

Percentage 1 Person

2 Persons

80%

$59,850

$68,400

100%

$74,760

$85,440

$104,200

3 Persons

4 Persons

$76,950

$85,450

$96,120

$106,800

United States

5 Persons

6 Persons

$93,200

$99,150

$115,344

$123,888

7 Persons

$106,000

$132,432

8 Persons

$112,800

$140,976

NOTE: In order to remain on the Waiting List, you must update periodically, even if the information

already given is still the same. Reminder: Notify the DNH of any changes that may

occur in your household. After a year with no update, you will be automatically removed from

the waiting list and will have to reapply.

I understand the above requirements and responsibilities of the Housing Assistance Program and I am submitting an

application:

Applicant Signature

Date

HOUSING ASSISTANCE APPLICATION

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Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

HOUSING ASSISTANCE APPLICATION

The following is a list of items that are needed in order to process your Delaware Nation Housing Assistance Application.

Your Delaware Nation Housing Assistance Application will not be processed until copies of these items are received.

Please send copies of all items that apply to your situation.

PLEASE CHECK EVERYTHING THAT YOU HAVE ENCLOSED:

ENCLOSE COPIES OF ALL HOUSHOLD MEMBERS TRIBAL ID CARDS

ENCLOSE COPIES OF ALL HOUSEHOLD MEMBERS SOCIAL SECURITY CARDS

ENCLOSE COPY OF MARRIAGE LICENSE OR DIVORCE DECREE (IF APPLICABLE)

ENCLOSE COPIES OF PAYSTUBS FOR HOUSEHOLD MEMBERS THAT ARE EMPLOYED

ENCLOSE COPIES OF CURRENT YEARS AWARD LETTER FOR SOCIAL SECURITY AND SSI DISABILITY

ENCLOSE COPIES OF ALL HOUSEHOLD MEMBERS BIRTH CERTIFICATES

PHONE NO:

CELL #:

APPLICANT CERTIFICATION:

I/We certify that the above and attached information are complete and accurate to the best of my/our knowledge and

belief. I/We understand that false statements or information are grounds for

termination of housing assistance and residency.

Head of Household Signature

Date

Spouse Signature

Date

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Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

HOUSING ASSISTANCE APPLICATION

APPLICANT NAME:

SSN:

TRIBE:

DOB:

PHONE #: (

_)

YRS LIVING HERE:

PLEASE LIST LANDLORDS FOR THE PAST 5 YEARS:

(We must have either a telephone number or address of the landlords listed.)

ADDRESS:

TO :

LANDLORDS NAME:

REASON FOR MOVING:

ADDRESS:

CONTACT NUMBER:

ADDRESS:

DATE FROM:

TO :

LANDLORDS NAME:

REASON FOR MOVING:

ADDRESS:

CONTACT NUMBER:

ADDRESS:

DATE FROM:

TO :

LANDLORDS NAME:

/

ROLL #:

MAILING ADDRESS:

DATE FROM:

/

REASON FOR MOVING:

ADDRESS:

CONTACT NUMBER:

PLEASE LIST (2) PERSONAL REFERENCES:

(Must not be related)

NAME:

ADDRESS:

PHONE:

NAME:

ADDRESS:

PHONE:

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_

Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

HOUSING ASSISTANCE APPLICATION

PLEASE LIST ADDITIONAL HOUSEHOLD MEMBERS, INCLUDING SPOUSE:

RELATION TO

NAME

D.O.B.

SSN

TRIBE

APPLICANT

INCOME?

ROLL

#

YN

YN

YN

YN

YN

YN

YN

PLEASE LIST ALL HOUSEHOLD INCOME:

(NOTE: You must include CHECK STUBS, AWARD LETTERS or STATEMENTS from EMPLOYERS with

your application)

Person with INCOME

TYPE of INCOME

MONTHLY

AMOUNT

ADDRESS of EMPLOYER

(Street/PO Box, Town, State, Zip

Code)

OTHER INCOME:

SS/SSI 

VA 

IIM 

CHILD SUPPORT 

PENSION 

UNEMPLOYMENT 

PENSION 

UNEMPLOYMENT 

NAME OF PERSON RECEIVING OTHER INCOME:

SS/SSI 

VA 

IIM 

CHILD SUPPORT 

NAME OF PERSON RECEIVING OTHER INCOME:

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Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

HOUSING ASSISTANCE APPLICATION

EMPLOYER INFORMATION:

APPLICANT:

SPOUSE:

Other ADULT:

Other ADULT:

NAME OF EMPLOYER

MAILING ADDRESS

P#

NAME OF EMPLOYER

MAILING ADDRESS

P#

NAME OF EMPLOYER

MAILING ADDRESS

P#

NAME OF EMPLOYER

MAILING ADDRESS

P#

PLEASE READ & ANSWER THE FOLLOWING QUESTIONS AS BEST AS YOU CAN:

Have you ever lived in a PUBLIC/INDIAN Housing Authority project? YES 

If YES, Where?

Do you own or are you purchasing a HOME? YES 

NO 

NO 

Have you or any other member of your family ever been evicted? YES 

If so, explain the circumstances:

NO 

Is anyone listed on this application HANDICAPPED or DISABLED? YES 

If YES, Who and What type?

NO 

Has anyone listed on this application ever been convicted of a FELONY? YES 

If YES, Who and What type?

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NO 

Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

HOUSING ASSISTANCE APPLICATION

PLEASE READ THE FOLLOWING STATEMENTS BEFORE SIGNING:

•

•

•

•

I certify that the information on this application is true and complete to the best of my knowledge

I understand that the information provided is used to determine eligibility and does not necessarily qualify me

for the program.

I give permission to the Delaware Nation Housing to make inquiries for the purpose of verification of statements

made in this application, including inquiries with any current or former landlords or employers.

I understand that providing false information may disqualify me or could result in the Delaware Nation Housing

evicting me from any premises that it later leases to me.

Applicant’s Signature

Date

Spouse’s Signature (if applicable)

Date

By signing this application, I certify under penalty of law that all information submitted in and with this

form is true and accurate. I further certify that any misuse of funds or fraudulently obtaining funds will

result in a reimbursement of fraudulent funds obtained and ineligibility of future assistance for any

Delaware Nation program assistance for one-calendar year from the date fraud was committed. I accept

the Terms and Conditions and agree to use these funds for the intended purpose stated within this

application

Applicant Signature

Date

Housing Director Signature

Date

NOTE: It is the responsibility of the applicant to notify the Delaware Nation Housing of any changes of address, income

or family composition and to respond to all correspondence received from the Delaware Nation Housing in a timely

manner. Failure to comply will result in the application becoming inactive.

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Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

HOUSING ASSISTANCE APPLICATION

NAHASDA Public Disclosures

Please indicate below if you are currently an employee of the Delaware Nation Housing, or have a relative or

business associate, who is one of the following: 1) an employee of the Delaware Nation Housing or 2) a

Delaware Nation Executive Committee member. Applicants who fall in this category will be publicly disclosed

at the Delaware Nation Housing office and have notification sent to the Office of Housing and Urban

Development (HUD) in Oklahoma City.

Applicant’s Name:

No, I am not an employee of the Delaware Nation Housing or a member of

the Delaware Nation Executive Committee, nor do I have relatives or business

associates who are employees of the Delaware Nation Housing or a member of the Delaware

Nation Executive Committee.

Yes, I am an employee of the Delaware Nation Housing or a member of the Delaware Nation

Housing Executive Committee.

Title:

Yes, I have a relative or business associate who is an employee of the Delaware Nation Housing

or a member of the Delaware Nation Executive Committee.

Name of Relative/

Business Associate

Relation to Applicant

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Relative/ Business

Associate Title

Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

HOUSING ASSISTANCE APPLICATION

Instructions: Applicant please only complete highlighted areas.

RE: Verification of Employment (please return completed form to above address)

Applicant Name:

SSN:

DOB:

The individual named above is an applicant/tenant for housing assistance that is subsidized through the U.S. Department of Housing

and Urban Development. Federal regulations require that in order for the household to be eligible, we must verify the household’s

income, expenses and other information using third party written verifications. The information you provide will be used only for the

purpose of determining the household’s eligibility for the program and will be held in strict confidence. We are required to

complete our verification process in a short time period and would appreciate your prompt response to this request for

information.

I, the undersigned, do hereby authorize the release of the information requested to Delaware Nation Housing.

Applicant / Tenant Signature:

Date:

(or see signed Authorization for the Release of Information

EMPLOYMENT INFORMATION: This section is to be completed by the employer.

Place of Employment:

Date Hired:

Occupation/Position:

CURRENT

Pay Rate: $

Per: Hour / Day / Week / Month (Circle one) Effective Date:

PREVIOUS

Pay Rate: $

Per: Hour / Day / Week / Month (Circle one) Effective Date:

ENTER THE AVERAGE NUMBER OF HOURS WORKED DURING THE PAST TWELVE (12) MONTHS:

Average Per DAY:

Per WEEK:

OVERTIME Per DAY:

Per WEEK:

OVERTIME RATE: $

ESTIMATED OTHER: Tips: $

Per: Hour / Day / Week / Month (Circle One)

Meals: $

Other: $

Is this employee participating in a job-training or vocational rehabilitation program? Yes No

Comments:

Date:

Signature:

Title:

Phone:

Warning! Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements or misrepresentations to any

Department or Agency of the United States as to any matter within its jurisdiction.

For Office Use Only:

Initial

Annual

Interim

*Occupancy Specialist:

Comments:

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Delaware Nation Housing

904 W. Petree

Anadarko, OK 73005

405 / 480-2220

Fax: 405 / 480-2223

HOUSING ASSISTANCE APPLICATION

NOTICE/AUTHORIZATION AND RELEASE FOR CRIMINAL BACKGROUND INVESTIGATION

Name of Head of Household on Housing Application:

I, the undersigned individual, do hereby authorize the Delaware Nation Housing, Anadarko, OK to procure a criminal background report on me for

the purpose of initial applicant eligibility screening, lease enforcement and/or eviction actions. This authorization and release form is valid during

the housing application process, and if accepted into a housing program, for the entire duration of stay in a DNH housing unit.

This above-mentioned report will be disclosed only to DNH staff who has a job related need for the information and who is an authorized officer,

employee, or representative of the recipient.

I further authorize any person, business entity or governmental agency who may have information relevant to the above to disclose the same to

the Delaware Nation Housing, Anadarko, OK including, but not limited to any and all courts and law enforcement agencies, regardless of whether

such person, business entity or governmental agency compiled the information itself or received it from other sources.

I hereby release the Delaware Nation Housing, Anadarko, OK and all persons, National Crime Information Center, police departments, and other

law enforcement agencies, from any and all liability, claims and/or demands, by me, my heirs or others making such claim or demand on my behalf,

for providing a criminal

background report hereby authorized.

Further, I certify that the information contained on this Notice/Authorization/Release form is true and correct and

that my housing application will be terminated based on any false, omitted or fraudulent information.

Signature:

Today’s Date:

(PLEASE TYPE OR PRINT CLEARLY IN INK)

Full Name:

[Do Not Abbreviate] First

Other Names Used:

Current Address:

Middle

-

Date of Birth (month/day/year):

City

State

-

SR

III

Dates Used:

(alias, maiden, or nicknames)

Street or P. O. Box

Social Security Number:

Suffix: JR

Last

Zip Code County

Date Lived

Full Name on SSN:

/

/

Gender: Female

Male

TO BE COMPLETED BY DNH STAFF ONLY

This criminal background report will be kept under lock and key and be under the custody and control of the DNH executive

director/lead official and/or his designee for such records.

Date Report Received:

Reviewed By:

Report Determination: Favorable / Unfavorable

Duplicate This Form As Necessary For Each Family Member 18 Years or Older

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