NEZ PERCE TRIBAL HOUSING AUTHORITY

NEZ PERCE TRIBAL HOUSING AUTHORITY

P.O. BOX 188 + LAPWAI, IDAHO 83540 - (208) 843-2229

105 RIVERVIEW AVENUE - KAMIAH, ID 83536 - (208) 935-2144

Application Instructions

Attached is the application for Housing Assistance. Please return the completed

application to the NPTHA Office with the following:

O Copies of Tribal Enrollment cards for all enrolled household members;

O Copies of Social Security Cards for all household members;

O Copies of most recent paycheck stubs and/or other household income;

0

IDA & Mortgage Finance Assistance applicant do not need to complete

sections 4 or 5.

You will receive notice within two weeks regarding the status of your application.

Once you are on the waiting list, you can check your status at our front office.

The waiting list is prioritized by preference points and application date thereafter.

All housing assistance provided by the NPTHA is subject to federal and state

income guidelines. Moderate income families may be eligible for various

programs, however, are not able to receive the same benefits as low income

families.

If you need assistance in completing this application, please contact the NPTHA

Office in either Lapwai or Kamiah.

Low Rent Programs

Low Rent Housing: The NPTHA manages Low Rent housing units in the Lapwai and Kamiah areas. Only

qualified low-income families are eligible for assistance. Applicants are placed on a waiting list with preference

given to Nez Perce families. The Low Rent program is a month-to-month lease and the rent is based on 30% of

adjusted gross income.

Low-Income Housing Tax Credit (LIHTC) Rentals: The NPTHA manages LIHTC units in the Lapwai area. Only

qualified low-income families are eligible for assistance. Although preference is provided to Nez Perce families,

various income restrictions apply. The LIHTC program accepts Section 8 vouchers and requires all tenants to

apply for Section 8 vouchers. Rents are calculated annually based on 30% of adjusted gross income.

Homeownership

Starter Home Program (SH): This program is a five-year lease with option to purchase and only applies to

available homeownership units the NPTHA built before 1998. Eligible applicants will earn credits during the

lease phase to buy down the purchase price. Only Nez Perce families who can complete the mortgage process

within five years are eligible.

Option to Purchase Program (OPP): This program is a three-year lease with option to purchase available for

our Sundown Heights homeownership units. Eligible applicants will earn mortgage payment credits during the

lease phase and receive buy-down assistance. Only Nez Perce families who can complete the mortgage process

within three years are eligible.

Financial Assistance

Individual Development Account (IDA): This is a savings program designed to encourage low-income Nez Perce

Families to save for 1) down payment to purchase home or 2) home repairs/improvements. The NPTHA will

provide a $2 match for every $1 saved toward the purchase of a home or a $1 for $1 match for home

repairs/improvements.

Mortgage Finance Assistance (MFA): Down payment and closing costs assistance is available for eligible low

and moderate income families who are purchasing a home through a private lender. MFA is not applicable

when buy-down assistance is provided by other NPTHA programs.

Home Repair Programs

Senior Rehab Program: This program provides assistance to low-income senior citizens who own their own

home. The grant amount is a maximum of $4,500 to complete essential repairs. The NPTHA will assist in

compiling estimates and arranging completion of repairs.

Education Classes

Education Classes:: The NPTHA provides the following Education Classes:

*Homebuyer Education: Overview of the program benefits and step by step process for those interested in

purchasing a home. Also, a requirement of Section 184 Guaranteed Loan program.

*Financial Literacy: Learn to manage your personal finances, understanding credit, etc...

*Renter's Rights & Responsibilities: A complete review for current tenants and future tenants.

*Maintenance Class: Learn various do-it-yourself maintenance tasks.

*Homeowners Maintenance Class: A guide to inspecting. and comoleting home repairs and improvements.

Nez Perce Tribal Housing Authority Paton la

Lapwai, ID 83540

(208)843-2229 Fax (208)843-2973

PART I: Housing Assistance Application

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SECTION 1: Application Information

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ASSISTANCE DESIRED

Applicant Name: Co-Applicant Name:

Home Phone: Work Phone: Home Phone: Work Phone:

Mailing Address:

Indicate the type of housing assistance you are applying for:

(Low Rent (Tax Credit Rental CO Starter Home (Purchase SDH Home

(J) Purchase SDH Lot ODA CO MFA (Other:

Desired location: Co Lapwai (Kamiah (Orofino (2 Other:

Do you presently own a home? YES] Nol] If yes, please provide address:

Are you presently a NPTHA participant? YES [] NO [] If you are presently a NPTHA participant, please explain.

Please indicate your housing goals:

What is your family’s current housing situation? OWN [] RENT 1] LIVE WITH FAMILY (] mH C] sHC] oTHerD

Does any household member owe any amount to NPTHA? yonoo Verified:

Have you completed our Homebuyer Education Class? yong Date Completed:

Have you completed our Financial Literacy Class? yoNno Date Completed:

Household

List all household members that are applying to live in this home with you and provide Social Security cards and Tribal ID.

i fi ‘, Tribal

Name Relationship Social Security Tribal Affiliation

First, Middle Initial, Last to Applicant | M/F Number is inapolisent DOB

Applicant

(01/2006)

SEC

Income and Asset Information

Applicant Co-Applicant

CURRENT EMPLOYMENT INFORMATION

Current Employer/Address Length: Current Employer/Address Length:

Yrs___Mo.__ Yrs, Mo.__

Position/Title Full-time [_] |Position/Title Full-time [7]

Part-time [—] Part-time [_]

|Gross Monthly Income ‘Net Mo. Income Gross Monthly Income ‘Net Mo. Income

IF EMPLOYED WITH CURRENT EMPLOYER LESS THAN 2 YRS, COMPLETE THE FOLLOWING SECTION:

Previous Employer Position/Title ‘Length Previous Employer Position/Title Length

Address Annual Income~ | Address Annual Income

ALL HOUSEHOLD INCOME

List all household income: Income is counted for anyone 18 or older (unless legally emanicipated). However, if the income is uneamed income such as a grant, benefit, trust

income, gaming dividends, or per captia dividends, it is counted for all household members including minors. Include all income ANTICIPATED for the next 12 months.

Household Member

Source Income

Amount Frequency

Income Questionaire

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Do YOU or ANYONE in your household receive OR expect to receive income from:

(Report all dollar amounts above)

Employment wages or salaries? (Include overtime, tips, bonuses commissions and payments received in cash.)

Self-employment? (Include overtime, tips, bonuses, commissions and payments received in cash.)

Regular pay as a member of the Armed Forces/Military?

Unemployment benefits or workman’s compensation?

Public Assistance, General Relief or Temporary Assistance for Needy Families (TANF)?

(a) Child support or Alimony?

(We must count court-ordered support whether or not it is received unless legal action has been taken to remedy. We must

also count support that is not court-ordered rather received directly from payer. Payments received in a lump sum will also be

counted.)

(b) How is the support received? (Check all that apply.)

Child Support Enforcement Agency

Court of Law

Directly from Individual

Other

Name of Agency:

Name of Court:

Name of Person:

Explain

YES .

1. (©) If support/alimony is court-ordered but not actually received, are you taking legal action to remedy?

Explanation:

8. (d) Have you received repayment(s) of past due child support? (If so, obtain third party documentation of

amounts, source, and dates.)

9; Social Security, SSI or any other payments from the Social Security Administration?

10. Regular payments from a Veteran’s benefit, Pension, retirement benefit or annuities?

ll. Regular payments from a severance package?

12. Regular payments from any type of settlement? (For example, insurance settlements.)

Payments from any per capita related to land claims settlements, dividends?

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14, Educational grants, scholarships, or other student benefits?

15. Regular gifts or payments from anyone outside of the household?

(This includes anyone supplementing your income or paying any of your bills.)

16. Regular payments from lottery winnings or inheritances?

17. Regular payments from rental property, trust, or other types of real estate transactions?

18. Any other income sources or types not listed?

19. Do you or any other household members expect any changes to your income in the next 12

months?

Explanation:

Asset Information

Include all assets held and the income derived from the asset. INCLUDE ALL ASSETS HELD BY ALL HOUSEHOLD MEMBERS INCLUDING MINORS.

Do YOU or ANYONE in your household have:

Of

YES

Oo

20. Checking or savings account?

Household Member Financial Institution Amount

oO im 21. CDs, money market accounts or treasury bills?

Household Member Financial Institution Amount

Oo oO 22. Stocks, bonds or securities?

Household Member Company or Broker Amount

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23.

Trust Funds?

Household Member Financial Institution Amount

Pensions, IRAs, Keogh or other retirement accounts?

Household Member Financial Institution Amount

Whole life insurance policy?

Household Member Financial Institution Amount

Real estate, rental property, land contracts/contract for deeds or other real estate holdings?

(This includes your personal residence, mobile homes, vacant land, farms, vacation homes or commercial property.)

Household Member Address of Property Amount

Personal property held as an investment?

(This includes paintings, coin or stamp collections, artwork, collector or show cars, and antiques. This does not

include your personal belongings such as your car, furniture or clothing.)

Household Member Item Amount

Have you or any other household members disposed of or given away any asset(s) for LESS than

fair market value within the past 2 years?

Household Member Amount

Explanation

Housing References

List housing references for the past 3 years. (If additional space is required, use the back of this application.)

Landlord’s Name/Address Your Address Own/Rent

Name: OWN From:

Address: To:

RENT

Phone: ( )

Name: OWN From:

Address: To:

RENT

Phone: ( )

Name: OWN From:

Address: To:

RENT

Phone: (__)

|

Vehicle Identification

List vehicle information for all vehicles that are owned or operated by any household member.

Vehicle #1

Tag/License Plate# State Issued Make/Model/Year

Vehicle #2

Emergency Contact

List an emergency contact.

Relationship: Years Known:

Background Information

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Do you expect any additions to the household within the next twelve months?

Name & Relationship:

Explanation:

Is there anyone living with you now who won’t be living with you at this property?

Name & Relationship:

Explanation:

Do you have full custody of your child(ren)? (if no, obtain proof of amount of time child(ren) will be living in unit.)

Explanation:

Are there any absent household members who under normal conditions would live with you? (For

example, a spouse away in the military.)

Explanation:

Does your household have or anticipate having any pets other than those used as service animals?

Explanation:

Have you or anyone else named on this application filed for bankruptcy?

Explanation:

Do you owe any money to a utility company?

Explanation:

Have you or anyone else named on this application been convicted of a felony?

Explanation:

Have you or anyone else named on this application been convicted for dealing or manufacturing illegal drugs?

Explanation:

Have you or anyone else named on this application been convicted of property damage?

Explanation:

Have you or anyone else named on this application been evicted from a rental unit of any type, including

a home, apartment, mobile home, etc.?

Explanation:

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Rental Program Questions

Applicant Status

The following questions pertain to specific eligibility requirements of the Tax Credit Program, please answer if you are applying for any rental program.

YES NO

oO oO 1. Do you or any other ADULT household members claim zero income?

Household Member

Explanation

oO oO a: Are you or any other household members (INCLUDING MINORS) currently a full-time student or

expect to be one in the next 12 months?

Household Member(s):

i] |e a: Will you or any ADULT household member require a live-in care attendant to live independently?

Name of Attendant:

Relationship (If any):

Oo oO 4. Will your household be receiving Section 8 rental assistance at time of move-in?

Name of Agency:

Contact Person:

Oo oO 5. Will your household be eligible or have you applied to receive Section 8 rental assistance? (YOU

MUST COMPLETE THE APPLICATION BEFORE BEING ELIGIBLE FOR NPTHA SUBSIDY.)

Date of Application:

‘Name of Agency:

SE ON 6: IDA and MFA Questions

Financial Assistance Questionaire

1. What type of home are you purchasing or interested in purchasing?

1 New manufactured ( New Home already built DO Existing home

(O Used manufactured (not eligible for IDA) Build anew home (1 Existing home w/improvements

2. Is the home your interested in purchasing located within the Nez Perce Reservation boundries (1855 Treaty)?

Oes ONo

3. Will the home you purchase be your primary residence (at least 9 months per year)?

Dyes CNo

4. Do you have a plan for completing your purchase?

Explain:

Estimated cost of home $, Estimated purchase ddate:,

Lender: Haye you prequalified for a loan:

5. Which costs are you requesting from Mortgage Finance Assistance:

Down Payment Ditsspection costs Appraisal costs DAttomey costs

6. Which costs are you saving for

Down payment goal amount: $. Inspections cost goal amount: $

Appraisal costs goal amount: $. Application fees goal amount: $.

Closing fees goal amount: $ Improvement costs goal amount: $

w/purchase of home

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ECTION 7: Signatures

Housing Counseling Agreement

Itis a proven fact that Housing Counseling and Homebuyer Education classes prevent problems for renters and homebuyers. In order to obtain housing assistance from the

NPTHA, pre and post counseling is required by NPTHA policy. The pre-counseling will include at least 4 to 12 hours of educational instruction offered in group

sessions, depending on the program assistance requested. Additional one-on-one counseling can be required based on the needs of the family as determined by the

NPTHA and the type of program assistance desired. Post counseling may also be required ona month to month basis.

Classes will be conducted by NPTHA Housing Counselors in the Homeownership Opportunity Center. All housing counseling requirements apply to the head or heads of

household; consequently, both heads of household or the equivalent must complete the required classes and housing counseling sessions. Scheduling of individual sessions will

be arranged to the greatest extent practical so that your work obligations are not interrupted.

Please indicate by your signature below that you understand that your participation in the Housing Counseling Program isa requirement for acceptance to the program and for

Continued occupancy. By your signature below you also agree to contact a NPTHA Housing Counselor to arrange for your participation in our classes.

Applicant Signature Date Co-Applicant Signature Date

Signature Clause

T understand that the NPTHA is relying on this information to verify my household’s eligibility for NPTHA housing assistance programs. I certify that all

information and answers to the questions contained in this application are true and complete to the best of my knowledge. I consent to release the necessary

information to determine my eligibility including minors who will reside in the home. I understand that providing false information or making false

statements is considered grounds for denial of my application. I also understand that such action may result in criminal penalties.

T authorize my consent to have the NPTHA verify the information contained in this application for purposes of proving my eligibility for occupancy and/or

any other housing assistance provided by the NPTHA. I will provide all necessary information including source(s) of income, names, addresses, phone

numbers, account numbers where applicable and any other information required for expediting the application process. I hereby authorize and instruct the

NPTHA to obtain and review my credit report for prequalifying purposes. I further understand that the NPTHA can at any time require a criminal

background check on any of the applicants and occupants residing in or applying to reside in the home. It is understood that assistance may be denied or

discontinued as a result of allegations or conviction of a crime that is a violation of the NPTHA policies.

My signature below also authorizes the release of account information from and to other financial institutions that I have supplied to the NPTHA in

connection with such evaluation. In other words, I understand that that the processing of this application will require providing my infomation to an

agency as well as an agency providing personal information to the NPTHA. I understand that acceptance for occupancy is contingent on all occupants

meeting NPTHA’s resident selection criteria and the applicable program requirements and policies as they now exist or as they may hereafter be revised OR

ADDED by the NPTHA.

Applicant Signature Date Co-Applicant Signature Date

All additional ADULT household members must sign below indicating consent for the release of information as described above:

Signature Date

Signature Date

Signature Date

Signature Date

Housing Counselor Signature Date

FOR OFFICE USE ONLY

~” Pre“qualification Summary

Total Household Income: monthly: $ annual: $ # of Household members: i

Income Classification: [>] Very Low Income [=jLow Income []Moderate Income [=@j|Above Moderate

Percentage of AMT Bedroom size eligible

Program eligible: TReeEInt@ 2s SH: “OPP slot. SIDA. MPA’

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Authorization for the Release of Information/

Privacy Act Notice

to the U.S. Department of Housing and Urban Development (HUD)

and the Housing Agency/Authority (HA)

U.S. Department of Housing

and Urban Development

Office of Public and Indian Housing

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

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

THA requesting release of information: (Gross out space if none)

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

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

HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for

keeping that information; (3) HUD to request certain tax return

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 the form. HUD andthe 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. 552a. HUD may disclose information

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

to other government agencies for law enforcement purposes, to

Federal agencies for employment suitability purposes and to HAs

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 become 18 years of age.

Persons who apply for or receive assistance under the following

programs are required to sign this consent form:

PHA-owned rental public housing

Turkey III Homeownership Opportunities

Mutual Help Homeownership Opportunity

Section 23 and 19(c) 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 incomeas referenced at Section 6103(1)(7)(A)

of the Internal Revenue Code.)

U.S. Internal Revenue Service (HUD only) (This consent is

limited to uneamed income [i.e., interest and dividends].)

Information may also be 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 provide 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.

Original is retained by the requesting oraanization.

ref. Handbooks 7420.7. 7420.8. & 7485 1

farm HIIN_ORRA ¢7/OAY

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 HAs that

receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first

independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In

addition, I must be given an opportunity to contest those determinations.

This consent form expires 15 months after signed.

Signatures:

Head of Household Date

‘Social Security Number (if any) of Head of Household ‘Other Family Member over age 18 Date

‘Spouse Date Other Family Member over age 16 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. 20004), 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 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 youprovide.

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 and 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 eli ility. Failure to provide

any of the requested information may result in a delay or rejection of your eligibility approval.

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 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 a misdemeanor and fined not more

than $5,000.

Any applicant or participantaffected 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.

Nez Perce Tribal Housing Authority

P.O. Box 188

Lapwai, ID 83540

(208) 843-2229 Fax (208) 843-2973

Employment Income Verification

Employers Name: Phone #:

Address: Fax #:

ee

The Applicant/Tenant named below has applied for occupancy in one of our homes or is a current tenant. Due to the requirements of

our various funding sources, we must verify all income and assets for this person and their household to determine eligibility. Please

complete the following information and return it as soon as possible to the NPTHA Office via mail or fax.

NPTHA Representative: Date:

Applicant/Tenant Release Statement:

ApplicantTenant Name: Social Security #:

| hereby authorize the release of the following information in order to determine my eligibility for occupancy in a unit managed by the Nez Perce

Tribal Housing Authority. Please complete this form in full and return to the NPTHA at your earliest convenience.

Signature:

Dat

THIS SECTION TO BE COMPLETED BY EMPLOYER

Please do not leave any sections blank; enter zero “0” or N/A.

Employee Name: Job Title

Presently Employed: O Yes Date first employed: Q No Last Date of Employment:.

Currently Wages/Salary : $ (check one)

O hourly O weekly 0 bi-weekly co monthly O semi-monthly OG yearly 0 other

Average # of regular hours per week: Year-to-date earnings: $ from through

(mm-de-yy) (mm-de-yyy

Overtime Rate: $ per hour Average # of overtime hours per week:

Shift Differential Rate: $ per hour Average # of differential hours per week:

Commissions, bonuses, tips, other: $ (check one)

Oo hourly 0 weekly 0 bi-weekly O monthly 0 semi-monthly O yearly OD other

List any anticipated change in the employee's rate of pay within the next 12 months: Effective Date:

If the employee work is seasonal or sporadic, please indicate the layoff period(s):

Additional Remarks:

Employers Signature Employer's Printed Name Date

Your assistance in completing this form accurately and timely is greatly appreciated! (NPTHA #1)

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Nez Perce Tribal Housing Authority

i P.O. Box 188

0 pis Lapwai, ID 83540

B ‘N ~\ '" (208) 843-2229 Fax (208) 843-2973

‘Employment Income Verification. ©. © -

Employers Name: Phone #:

Address: Fax #: a

a

The ApplicantTenant named below has applied for occupancy in one of our homes or is a current tenant. Due to

our various funding sources, we must verify all income and assets for this person and their household to determin:

complete the following information and return it as soon as possible to the NPTHA Office via mail or fax.

the requirements of

e eligibility. Please

NPTHA Representative:_. Date:

"- Applicant/Tenant

Applicant/Tenant Name: Social Security #:

| hereby authorize the release of the following information in order to determine my eligibility for occupancy in a unit managed by the Nez Perce

Tribal Housing Authority. Please complete this form in full and return to the NPTHA at your earliest convenience.

Signature: Date:

eee ee

THIS SECTION TO BE COMPLETED BY EMPLOYER

Please do not leave any sections blank; enter zero “0” or N/A.

Employee Name: Job Title

Presently Employed: O Yes Date first employed: 1 No Last Date of Employment:

Currently Wages/Salary : $ (check one)

o hourly Oo weekly 0 bi-weekly Q monthly © semi-monthly O yearly 0 other

Average # of regular hours per week: Year-to-date earnings: $ from through

(mm-dd-yy) (mm-dd-yy)

Overtime Rate: $ per hour Average # of overtime hours per week:

Shift Differential Rate: $ per hour Average # of differential hours per week:

Commissions, bonuses, tips, other: $ (check one)

O hourly O weekly O bi-weekly a monthly 0 semi-monthly OD yearly O other

List any anticipated change in the employee's rate of pay within the next 12 months: Effective Date:

If the employee work is seasonal or sporadic, please indicate the layoff period(s):

Additional Remarks:

Employers Signature Employer's Printed Name Date

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General Income Verification

Source’s Mailing Address: Phone #: | ( )

Fax #: ( |

Requestor: Date:

The applicant named above has applied for housing assistance to be provided through the Nez Perce Tribal Housing Authority Program,

We must verify all income and asset sources of this person and their household to determine eligibility. Please complete the following

information and return as soon as possible to the NPTHA Office.

Your assistance in completing this form accurately and timely is greatly appreciated!

Applicant/Tenant Release Statement:

Applicant/Tenant Name: Date:

Thereby authorize the release of the following information in order to determine my elig

ility for the Nez Perce Tribal Housing Program.

Please complete this form in full and return it to the NPTHA at your earliest convenience,

Signature: Social Security #:

Check the type(s) of income received, the GROSS amount CURRENTLY receiving and date began receiving benefit:

Income Type Amount Frequency Date First Started

Q | Earned Wages $

Q | General Assistance $s

O | Unemployment Ss

Q | Veteran’s Benefit, Retirement Pay or Annuity $

Q | Disability/Sst $

Q | TANF $

S | Income from Real Estate/Lease $

© | Child Support, Alimony, Etc. $

Q | Per Capita $

Q | Income from Real Estate/Lease: $

O | Other: $

(Please list type)

Signature of Source:

Date Completed Form: Phone #:

Comments:

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General Income Verification

Source’s Mailing Address: Phone #:_| ( )

Fax #: ( )

Requestor: Date:

The applicant named above has applied for housing assistance to be provided through the Nez Perce Tribal Housing Authority Program.

We must verify all income and asset sources of this person and their household to determine eligibility. Please complete the following

information and return as soon as possible to the NPTHA Office.

Your assistance in completing this form accurately and timely is greatly appreciated!

Applicant/Tenant Release Statement:

Applicant/Tenant Name:

I hereby authorize the release of the following information in order to determine my eli

Please complete this form in full and return it to the NPTHA at your earliest convenience.

lity for the Nez Perce Tribal Housing Program.

| Signature: Social Security #:

Check the type(s) of income received, the GROSS amount CURRENTLY receiving and date began receiving benefit:

Income Type Amount Frequency Date First Started

Q | Earned Wages $

Q | General Assistance $

Q | Unemployment $

Q | Veteran’s Benefit, Retirement Pay or Annuity $

Q | Disability/SsI $

Q | TANF $

O | Income from Real Estate/Lease Ss

Q | Child Support, Alimony, Etc. $

QO | Per Capita $

Q | Income from Real Estate/Lease: $

O | Other: $

(Please list type)

Signature of Source:

Date Completed Form: Phone #:

Comments:

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Landlord Reference. Check

Name of Applicant:

Home Community Applying For:

Reference Performance Method:

Telephone Person-to-Person Written

Name of Person Performing Reference:

Address of Previous Residence:

Type of Residence Own Rental Other

Landlord’s Name:

Phone #: ( ) Fax#: _( )

Type of Landlord: Management Co. Real Estate Co. Private Owner

Dates of Residency: From: To:

Amount of Monthly Rent: # of Occupants:

# of Late Payments: # of Returned Checks:

# of Disturbance Complaints: # of Times Police Called:

YES NO

1. Did the resident or his family/guests damage the home or the property? o o

2. Did the resident pay for the damages? o o

3. Did the resident violate the lease agreement in any way? 0 a)

4, Did the resident violate any of your house rules in any way? a) a)

5. Did the resident give the proper notice for vacating the unit? 0 a

6. Would you rent to this individual again? im) a

7. Did the resident have any pets? a a)

Applicant/Tenant Release Statement & Signature: |

I Hereby Authorize the release of the above information to determine my eligibility for the Housing Credit Program. Please complete this

form in full and retum it to the NPTHA at your earliest convenience.

Signature: SSN#

Signature: Date:

Title:

Office Use Only:

Date Received: Comments:

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