Otoe-Missouria Housing Department (2024)

Otoe-Missouria Housing Department

405 Wendall Drive, Red Rock, OK 74651

Office: (580) 723-4400 Fax: (580) 723-4590

HOUSING APPLICATION

Attached is the application for Low-Income Housing with the Otoe-Missouria Tribe Housing

Department. All forms and pages of the application must be filled out completely and the following

information/documentation is required to be submitted with your application to be considered

completed:

Low-Income Housing Application filled out and signed by all adults (18 years and older).

Release of Information Form signed by all adult household members.

Federal Privacy Act Statement signed by all adult household members.

Affidavit to Abide by Tribal ordinances signed by all adult household members.

Filled out and Signed Background Check / Consumer Report Disclosure & Release Form. One

form completed for each household member 18 years of age and older.

6. Copy of All person(s) in the household Driver’s License or State Issued Identification that is 18

years of age and older.

7. Copy of Tribal Membership Cards for all tribal members of the household. (Adults & Children)

8. Copy of Social Security Cards for all members of the household. (Adults & Children)

9. Minor children listed as household members or dependents must have legal custodial

documentation and birth certificate submitted with application.

10.Current Income Statements and verifications for all forms of household income. Or if Applicant

or adult household member does not have any income they will need to complete a zero-income

form.

OQ ge eb

Your application is not considered complete unless all necessary information is received. No assistance

will be provided until all required information is received, regardless of situation. Your completed

application will be processed within 30 days after it is received by our department. Please contact us if

you have any questions. Applicants can pick up a copy of our Housing Admission, Eligibility, and

Occupancy Policy at our office location.

Sincerely,

Housing Department

Otoe-Missouria Housing Department

405 Wendall Drive, Red Rock, OK 74651

Office: (580) 723-4400

Fax: (580) 723-4590

THIS BOX IS FOR OFFICE USE ONLY:

Received Date & Time:

Received By Staff Name:

Verified Completed Date & Time:

Application Number:

APPLICATION FOR NAHASDA PROGRAM SERVICES & OCCUPANCY

A) Please check which program(s) you are requesting occupancy?

LL] NAHASDA Low Income Housing (Single or Family Applicants, Village area)

C1 NAHASDA Low Income Elders Designated Housing (Applicants 62 yrs & older, Elder Units, no children)

CL] NAHASDA Lease to Purchase (Single or Family units, As funded under program for purchase)

B) Applicant / Head of Household Information:

Applicant Name (First and Last):

Address: City: State: Zip:

Phone #: Message Phone #:

Cell #:

C) Family Composition:

List everyone that you intend to reside in the unit.

First Name Last Name Date of | Sex | Social Security | Relation | Tribe Affiliation &

Birth | M/F Number to Enrollment

Applicant Number

Head of

Household

« Relation to Applicant/Head of Household can be listed as:

Co-Head/Spouse, Child, Adult Household Member.

« All adults (age 18 yrs old +) must submit copy of state ID or Driver’s license.

« Minor children listed as household members or dependents must have legal custodial documentation and birth

certificate submitted with application.

¢ Must submit copies of Social Security Cards and Tribal Membership (CDIB’s) for all persons named on the

application.

D) Income/ Assets:

Applicant must provide income verification for everyone listed on the application and report all forms of

household income. Failure to properly report income can result in denial of services.

Head of Household Employment Income

Co-Head of Household Employment Income

Applicant Name:

Applicant Name:

OPermanent LiTemporary

Employer: Employer:

Address: Address:

Employer Phone Number: Employer Phone Number:

Are you: OIFull Time UO Part Time Are you: [Full Time CH Part Time

OiPermanent_L]Temporary

Hourly Wage: Salary:

Hourly Wage: Salary:

Hours Worked Per Pay Period:

Hours Worked Per Pay Period:

Overtime Worked Per Pay Period:

Overtime Worked Per Pay Period:

Are You Paid: Weekly DIBi-Weekly

O) Monthly OOBi-Monthly [ Other:

Are You Paid: Weekly CIBi-Weekly

Ci Monthly DOBi-Monthly O Other:

Estimated Miles Round Trip to and from Work:

Estimated Miles Round Trip to and from Work:

CJ] Not Employed

C1 Not Employed

Other Household Member Employment Income

Other Household Member Employment Income

Applicant Name:

Applicant Name:

OiPermanent [LJTemporary

Employer: Employer:

Address: Address:

Employer Phone Number: Employer Phone Number:

Are you: OIFull Time (1 Part Time Are you: CFull Time C Part Time

[Permanent LITemporary

Hourly Wage: Salary:

Hourly Wage: Salary:

Hours Worked Per Pay Period:

Hours Worked Per Pay Period:

Overtime Worked Per Pay Period:

Overtime Worked Per Pay Period:

Are You Paid: Weekly LMIBi-Weekly

C] Monthly CBi-Monthly [] Other:

Are You Paid: Weekly [Bi-Weekly

C] Monthly OBi-Monthly [1 Other:

Estimated Miles Round Trip to and from Work:

Estimated Miles Round Trip to and from Work:

C1 Not Employed

L] Not Employed

NAHASDA Housing Services Application 03/2019

Page 3 of 14

Other Employment Income

Other Employment Income

Applicant Name: Applicant Name:

Employer: Employer:

Address: Address:

Employer Phone Number: Employer Phone Number:

Are you: OFull Time [J Part Time

ClPermanent LiTemporary

Are you: OFull Time O Part Time

OPermanent LJTemporary

Hourly Wage: Salary:

Hourly Wage: Salary:

Hours Worked Per Pay Period:

Hours Worked Per Pay Period:

Overtime Worked Per Pay Period:

Overtime Worked Per Pay Period:

Are You Paid: OWeekly LMIBi-Weekly

O Monthly OBi-Monthly 1 Other:

Are You Paid: Weekly UDIBi-Weekly

O Monthly OBi-Monthly CO Other:

Estimated Miles Round Trip to and from Work:

Estimated Miles Round Trip to and from Work:

U1 Not Employed

Oi Not Employed

Additional Income Information:

List all other income sources received other than employment wages. Also submit a current income verification

for each reported income source (check stub, benefits letter, bank statements, etc.)

Type of Income

Amount Received

How Often is

Income Received

Who is Receiving Income

Tribal Per Capita \

Tribal Revenue Sharing

Social Security Disability

Social Security Income

Pension / Annuity

IRA’s Payments / 401 K

Fringe Benefit Money Amount

Withdrawn and Received

Annual Bonuses

VA Benefits

Alimony

Child Support Ordered to be

Received (Provide copy of court

order)

Unemployment

Workers Compensation

Dividends

TANF

Commissions and Fees

Farm Income

Auto Resale

Seasonal Work

Prizes, Gambling, Lottery

Winnings

Self-Employment Income from

odd jobs (lawn work, food sales,

craft sales, babysitting, etc.)

NAHASDA Housing Services Application 03/2019

Page 4 of 14

Financial Assistance from

Family or Others for groceries,

utilities, or other household

supplies

Other:

Zero Income:

Any adult on the application that is claiming zero income must complete a zero-income form.

Name of Applicant Amount of Last Date of Last Income | Completed Zero Income

with Zero Income Income Received Received Form to Attach to

Application

OYes ONo

OYes ONo

OYes ONo

Assets:

1. Do you or any household member currently own or have any ownership interest in any home, real estate,

boat, mobile home? OYes Explain: CO No

2. Have you or any household member sold or leased out any real estate in the last 12 months?

OYes Explain: Sale Amt: $ O1No

3. Do you or any household member own any stocks and bonds, investments, trusts, or securities?

O1 Yes Institution: Acct Balance: $ OO No

4. Do you or any household member have a savings account or checking account with a banking

institution?

Ol Yes Bank Name: Acct Balance: $ [1 No

E) Other Information:

1. Do you currently Rent/Lease another home? C1] Yes C1 No

Current Land lord/Owner Name:

Land lord/ Owner Phone:

Monthly Rent Amount: $ Estimated Monthly Utility Costs: $

2. Have you or any household member ever received housing services from another Tribe/Tribal Housing

Authority or Public Housing Authority (Section 8)?

If Yes, Tenant Name: Housing Program:

Dates of Occupancy under that program:

CO Yes ONo

Reason of Moving Out\Ending Services:

NAHASDA Housing Services Application 03/2019 Page 5 of 14

3. Have you or any other household member been evicted from a housing rental lease, month to month home

rental agreement, or other housing rental agreement?

UO Yes ONo

If Yes, List When and Landlord Name:

4. Do you currently own any pets, that you intend to have residing at our rental unit?

O Yes C1 No

If Yes, Number of Pets: Kinds of Pets:

5. Do you or your spouse have any relative(s) currently working for, or holding office in this Tribe or Tribal

Housing Program?

0 Yes C1 No

6. Does the head of household or other household member have any of the following expenses?

Childcare? CI] Yes Monthly Amt Paid $ Provider Name: ONo

7. Have you or household member been charged/convicted of the following

Violent Crime(s)? 0 Yes C1 No

Felony Drug Crime(s)? U1 Yes CNo

Sex Offender Registry Status? 0 Yes C1 No

Felony Child Abuse or Neglect? C1 Yes ONo

Felony Assault & Battery? U1 Yes XO No

Felony Domestic Violence? U1 Yes 01 No

If Yes, Explain:

8. Are you or any household members listed on application temporarily absent from the home more than 30

days per calendar year due to work or school?

Cl Yes CNo

If Yes, Explain:

9, Are there any full-time students, 18 years old and older, in your household?

0 Yes C1 No

If Yes, Student Name: School Attending:

Does the student live with you and commute to school? LI Yes ONo

Does the student live in the Dorms during school semesters? Ol Yes C1 No

Does the student plan to live with you during school breaks and closure? O Yes OO No

Does the student live in other rental housing during school semesters? C1 Yes XO No

10. Are you or any household member disabled as defined by 24 CFR Part 1000.10?

U1 Yes CO No

Tf Yes, Whom: (Make sure to provide copy of SSD or SSI benefits

statements. If not receiving SSD, must have physician fill out form HUD-90103 Verification of Disability)

NAHASDA Housing Services Application 03/2019 Page 6 of 14

11. Does a member of your household require any of the following accommodations? (check if needed)

____ Live-In Caregiver (Verified by Physician)

____ Wheelchair accessible bathroom fixtures and shower

____ Wheelchair accessible doors

____ Wheelchair accessible kitchen fixtures and counters

Hearing impaired accommodations

Other Needs List Here:

No disability accommodations needed at this time

F) Residential History:

Please list residential history for at least the past 5 years

Former Address

Dates of Move-In and Move-Out

Former Land

Lord/Owner Name

Land lord Contact

Address & Phone

Number

Move-In Date:

Move-Out Date:

Why Moved:

Do you still owe for past rent? OC Yes L1No

If yes Amount still owed? $

Move-In Date:

Move-Out Date:

Why Moved:

Do you still owe for past rent? C1 Yes [1 No

If yes Amount still owed? $

Move-In Date:

Move-Out Date:

Why Moved:

Do you still owe for past rent? LJ Yes D1 No

If yes Amount still owed? $

Applicant additional Comments:

NAHASDA Housing Services Application 03/2019

Page 7 of 14

G)APPLICANT(S) CERTIFICATION / SIGNATURE

Thereby certify that all the information provided on this application is true and correct. I understand that

falsification of this information shall be grounds for denial of services and I may be subject to prosecution under

the law. I further give my permission for Otoe-Missouria Tribe Housing Department Staff to verify all the above

statements and information provided. I also acknowledge that this program is a federally funded by U.S.

Department of Housing and Urban Development (HUD). I understand that the above information is being

collected to determine my/our eligibility for program assistance and housing occupancy.

I understand that it is my responsibility to update my application before December 31* of each year. I

acknowledge that I can update my application by calling or going to the Otoe-Missouria Tribe Housing Office. I

will cooperate in supplying all information needed to determine my eligibility and failure to do so will result in

program denial. I understand that program eligibility is stated in the Housing Admission, Eligibility, and

Occupancy Policy and that I can pick up a copy at the Otoe-Missouria Tribe Housing Office.

By Signing below, I acknowledge that the housing units and program are owned and operated by the Otoe-

Missouria Tribe and financially funded under HUD NAHASDA grant program. I acknowledge that the Otoe-

Missouria Tribe Housing Program and daily operation is subject to HUD Regulations and Guidelines. I

acknowledge that it is my responsibility to read and comply with the Housing Admission, Eligibility, and

Occupancy Policy for program eligibility and participation.

Signatures & Date: (Everyone listed on the application that is 18 year and older must sign below)

Applicant/Head of Household Date

Co-Head/Spouse Date

Other Adult Household Member Date

Other Adult Household Member Date

NAHASDA Housing Services Application 03/2019 Page 8 of 14

Otoe-Missouria Housing Department

405 Wendall Drive, Red Rock, OK 74651

Office: (580) 723-4400 Fax: (580) 723-4590

AUTHORIZATION FOR RELEASE OF INFORMATION

CONSENT:

I authorize and direct the Otoe-Missouria Tribe Housing Department to gather information, documentation, or

materials needed to complete and verify my application for participation in and/or maintain my continued

participation eligibility under the Otoe-Missouria Tribe Housing Department services and programs.

INFORMATION COVERED:

Identify and Marital Status Medical or Child Care Allowance

Employment, Income, and Assets _ Residential and Rental Activity

Credit History Criminal and Drug Activity and History

Child Custody Tribal Enrollment

Outstanding debts Services Participation Current and Past/ Services Received

GROUPS OR INDIVIDUALS THAT MAY BE ASKED:

I understand that previous or current information regarding my household or myself may be needed. Verification

and inquiries that may be requested include, but are not limited to:

Previous landlords Social Security Administration

Schools and Colleges Law Enforcement Agencies (State and Tribal)

Court and Post Offices Support and Alimony Providers

Welfare Agencies State Unemployment Agencies

Veterans Administration Medical and Child Care Providers

Utility Companies Retirement Systems

Credit Providers Bank, Credit Bureaus

Past & Current Employers Otoe-Missouria Tribal Utility Authority & Records

Otoe-Missouria Tribal Loan Program Tribal Administration Records

Tribal Enrollment Records Department

Tribal General Fund Department Records

CONDITIONS:

I agree that a photocopy of this authorization may be used for the purposes stated above. The original of the

authorization is on file with the Otoe-Missouria Tribe Housing Department and will stay in effect for two years from

the date signed.

Applicant Signature Date Other Adult Signature Date

Ce: Tenant File Other Adult Signature Date

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

OMB Control Number 2577-0295

Expiration Date 1/31/2025

PHA requesting release of information; (Cross out 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)

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

soutces listed on the 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. 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 improperuses 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

Turnkey 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 J 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.)

US. Internal Revenue Service (HUD only) (This consent is

limited to unearned 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). [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 organization.

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 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 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. 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 ofthe 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 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 eligibility. 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 participant affected 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.

Original is retained by the requesting organization. ref, Handbooks 7420.7, 7420.8, & 7465.1 form HUD-9886 (7/94)

Please read carefully, Each adult member listed on the application must sign below. If you choose not to sign

this statement, please provide a written explanation for refusal.

AFFIDAVIT REGARDING TRIBAL ORDINANCES

I (We) understand the Low-Income Rental Program and housing units are under management of

the Otoe-Missouria Tribe. The housing units are located on land, which has been declared

“Indian Country”, and is therefore under the jurisdiction of the Otoe-Missouria Tribal

Ordinances and Laws.

I (We), further understand that by residing in one of the Low-Income Rental Program units

managed by the Otoe-Missouria Tribe Housing Department, I (We) are subject to ordinance and

laws of the Otoe-Missouria Tribe of Indians and are also subject to having these laws and

ordinances enforced by the Otce-Missouria Tribe Police Department and Court System.

I (We), hereby agree to abide by the ordinances and laws of the Otoe-Missouria Tribe, and agree

to the enforcement of these laws by the Otoe-Missouria Tribal Police Department and Court

Systems.

AGREED UPON THIS DAY OF

Day Month Year

Signature of Head of Household

Signature of Spouse (Co-Head)

Signature of Other Adult Household Member

Signature of Other Adult Household Member

NAHASDA Housing Services Application 03/2019 Page 12 of 14

AUTHORIZATION FOR BACKGROUND CHECK

This release of information constitutes my consent and authorization to the agonies or representatives identifies to furnish

OTOE MISSOURIA TRIBE HOUSING DEPARTMENT and MAXIMUM REPORTS, INC., and/or its representative’s permission and

authority to conduct a background check in order to determine my suitability for housing occupancy and housing program

participation with OTOE MISSOURIA TRIBE HOUSING DEPARTMENT. | understand and consent to an investigation that is

limited to criminal and civil record history information, motor vehicle driving history, human services inquiry for domestic

violence, child abuse, and neglect information, employment verification, educational verification, professional incensing,

personal and professional references, whether or not such information would otherwise be protected from disclosure by any

constitutional, statutory, or common law privilege.

| authorize the custodians of such records and sources of information to release the information, including permitting the

review and copying of all documents, records, or correspondence pertaining to me, to the representatives of OTOE MISSOURIA

TRIBE HOUSING DEPARTMENT and MAXIMUM REPORTS INC., regardless of any previous agreement to the contrary.

| agree to accept all risks of adverse public notice, embarrassment, criticism, or financial loss that may result from use of

information that is obtained in connection with a background investigation for the purpose listed in this document.

| agree to indemnify and hold harmless any person to whom this is lawfully presented and his agent and employees from and

against all claims, damages, losses, and expenses, including reasonable attorney's fees, arising out of by reason of complying

with this request.

APPLICANT’S FULL NAME TRIBAL AFFILIATION

MAIDEN NAME/AKA SOCIAL SECURITY NUMBER

ADDRESS DATE OF BIRTH

CITY, STATE, ZIP CODE DRIVER’S LICENSE NUMBER/ STATE

APPLICANT’S SIGNATURE DATE

NAHASDA Housing Services Application 03/2019 Page 13 of 14

AUTHORIZATION FOR BACKGROUND CHECK

This release of information constitutes my consent and authorization to the agonies or representatives identifies to furnish

OTOE MISSOURIA TRIBE HOUSING DEPARTMENT and MAXIMUM REPORTS, INC., and/or its representative’s permission and

authority to conduct a background check in order to determine my suitability for housing occupancy and housing program

participation with OTOE MISSOURIA TRIBE HOUSING DEPARTMENT. | understand and consent to an investigation that is

limited to criminal and civil record history information, motor vehicle driving history, human services inquiry for domestic

violence, child abuse, and neglect information, employment verification, educational verification, professional incensing,

personal and professional references, whether or not such information would otherwise be protected from disclosure by any

constitutional, statutory, or common law privilege.

| authorize the custodians of such records and sources of information to release the information, including permitting the

review and copying of all documents, records, or correspondence pertaining to me, to the representatives of OTOE MISSOURIA

TRIBE HOUSING DEPARTMENT and MAXIMUM REPORTS INC., regardless of any previous agreement to the contrary.

| agree to accept all risks of adverse public notice, embarrassment, criticism, or financial loss that may result from use of

information that is obtained in connection with a background investigation for the purpose listed in this document.

| agree to indemnify and hold harmless any person to whom this is lawfully presented and his agent and employees from and

against all claims, damages, losses, and expenses, including reasonable attorney's fees, arising out of by reason of complying

with this request.

APPLICANT’S FULL NAME TRIBAL AFFILIATION

MAIDEN NAME/AKA SOCIAL SECURITY NUMBER

ADDRESS DATE OF BIRTH

CITY, STATE, ZIP CODE DRIVER’S LICENSE NUMBER/ STATE

APPLICANT'S SIGNATURE DATE

NAHASDA Housing Services Application 03/2019 Page 14 of 14

Social Security Administration Form Approved

Consent for Release of Information OMB No, 0960-0586

You must complete all raquired fields. We will Not honor your requast unless all tequired fields are completed, (*Signifies a

required field. “Please complete these fields in case we eed to contact you about the consent form)

TO: Social Security Administration

*My Full Name *My Date of Birth “My Social Securlty Number

(NIN/DDIYYYY)

| authorize the Social Security Administration to release information or tecords about me to:

*MAME OF PERSON OR ORGANIZATION: “ADDRESS OF PERSON OR ORGANIZATION:

Otoe-Missourla Tribe Housing Department 405 Wendell Drive

Red Rock, OK 74651

Phone: 580-723-4466 Ext 345

*E want this information released because: Verification of benefits to determine brogram eligibility

Ve may charge a fee to relaase information for non-program purposes.

*Flease raleage the following information selected from the list below:

Chhack at least one box. We will rot disclose records unless you include date ranges where applicable.

1. (1 Verification of Sociat Security’ Number

2. [x Currant monthly Social Security benefit amount

3.) Current monthly Supplemental Security Income payment amount

4. 1] My benefit or payment amourits from date * to date”

8. [| My Medicare entitlement frorn date to date

6. [7] Medical records from my claims folder(s) from date fo date,

If you want us to release a minor child's medical records, do not use this form. Instead, contact your local Social

Security office,

7. [1 Complete medical records from my claims folder(s)

8. [other recard(s) from my file (Ye will not honor a request for "any and all records" or "the entlre file." You must specify

other records; ¢.g., consultative exams, awardidenlal hotices, benefit applications, appeals, quastionnalres,

doctor reports, daterminations.)

1 zm the Individual, to whom the requested Information or record applies, or the parent or legal guardian of a minor, or the

legal guardian of a legally incompetent adult, | declare under penalty of perjury (28 GFR § 16.44{d)(2004) that I have examined

all! the Information on this form and itis rue and correct to the best of my knowledge. | understand that anyone wha knowingly

or willfully seeking or obtaining access to records about another Petsen tinder false pretenses Is punishable by a fino of up to

$5,000. also understand that I must pay all applicable faes for requesting information for a non-program-related purpose.

“Signature: *Date: :

** Address: “Daytime Phone:

ne

Fe elatioriship (if not the subject of the record): “Daytime Phone:

a

Witnesses rust sign this form ONLY if the abave signature is by mark ®. Hf signed by mark (X}, two witnesses to the signing

wkio know the signee must sign belaw and provide their full addresses. Please print the signee's name next to the mark {X) on the

signature line above.

1 .Slgnature of wliness 2.8ignature of witness

A.ddress(Number and street, City,State, and Zip Cade) Address(Number and street, Clty, State, and Zip Code)

Feorm 8A-3268 (11-2016) uf

NA HASDA Housing Services Application 03/20 19 Page IS of 19

VERIFICATION OF U.S. Department of Housing OMB Approval No. 2502-0204

DISABILITY and Urban Development (Exp. 06/30/2017)

Office of Housing

Federal Housing Commissioner

ALL PROGRAMS EXCEPT

SECTION 202/8, SECTION 202 PAC,

SECTION 202 PRAC, AND

SECTION 811 PRAC

Appendix 6-B: SAMPLE VERIFICATION OF DISABILITY WHEN ELIGIBILITY FOR ADMISSION OR

QUALIFICATION FOR CERTAIN INCOME DEDUCTIONS IS BASED ON DISABILITY

FOR USE WITH ALL PROGRAMS EXCEPT SECTION 202/8, SECTION 202 PAC,

SECTION 202 PRAC, AND SECTION 811 PRAC

DATE:

TO: FROM:

RETURN THIS VERIFICATION TO THE PERSON LISTED ABOVE (or other instructions to the third party

to ensure that the verification is returned to the right person. This is important because owners have a

responsibility to treat this information confidentially.)

SUBJECT: _ Verification of Disability

NAME

ADDRESS

This person has applied for housing assistance under a program of the U.S. Department of Housing and

Urban Development (HUD). HUD requires the housing owner to verify all information that is used in

determining this person’s eligibility or level of benefits.

We ask your cooperation in providing the following information and returning it to the person listed at the

top of the page. Your prompt return of this information will help to ensure timely processing of the

application for assistance. Enclosed is a self-addressed, stamped envelope for this purpose. The

applicant/tenant has consented to this release of information as shown above.

INFORMATION BEING REQUESTED

For each numbered item below, mark an “X’ in the applicable box that accurately describes the person

listed above.

1._ YES __ NO Has a disability, as defined in 42 U.S.C. 423, which means;

a. Inability to engage in any substantial gainful activity by reason of any

medically determinable physica! or mental impairment that can be

expected to result in death or that has lasted or can be expected to

last for a continuous period of not less than 12 months; or

APPENDIX 6-B 1084 form HUD-90103 (12/2007)

ref. HB 4350.3 Rev. |

SAMPLE VERIFICATION OF U.S. Department of Housing OMB Approval No. 2502-0204

DISABILITY

ALL PROGRAMS EXCEPT

and Urban Development (Exp. 06/30/2017)

Office of Housing

Federal Housing Commissioner

SECTION 202/8, SECTION 202 PAC,

SECTION 202 PRAC, AND

SECTION 811 PRAC

2. YES _|

3. YES __|

APPENDIX 6-B

b. In the case of an individual who has attained the age of 55 and is

blind, inability by reason of such blindness to engage in substantial

gainful activity requiring skills or abilities comparable to those of any

gainful activity in which he/she has previously engaged with some

regularity and over a substantial period of time.

For the purposes of this definition, the term blindness, as defined in

section 416(i)(1) of this title, means central vision acuity of 20/200 or

less in the better eye with use of a correcting lens. An eye which is

accompanied by a limitation in the fields of vision such that the widest

diameter of the visual field subtends an angle no greater than 20

degrees shall be considered for the purposes of this paragraph as

having a central visual acuity of 20/200 or less.

Has a physical, mental, or emotional impairment that:

a. Is expected to be of long-continued and indefinite duration;

b. Substantially impedes his or her ability to live independently; and

c. Is of such a nature that the ability to live independently could be

improved by more suitable housing conditions.

Has a developmental disability as defined in Section 102(7) of the

Developmental Disabilities Assistance and Bill of Rights Act 42 U.S.C.

6001(8)), ie., a person with a severe chronic disability that:

a. Is attributable to a mental or physical impairment or

combination of mental and physical impairments;

Is manifested before the person attains age 22;

Is likely to continue indefinitely;

d. Results in substantial functional limitation in three or more of the

following areas of major life activity:

(1) Self-care,

(2) Receptive and expressive language,

(3) Learning,

(4) Mobility,

(5) Self-cirection,

(6) Capacity for independent living, and

(7) Economic self-sufficiency; and

a. Reflects the person's need for a combination and sequence of

special, interdisciplinary, or generic care, treatment, or other services

that are of lifelong or extended duration and are individually planned

and coordinated.

2 of 4 form HUD-90103 (12/2007)

ref. HB 4350.3 Rev. 1

SAMPLE VERIFICATION OF U.S. Department of Housing OMB Approval No. 2502-0204

DISABILITY and Urban Development (Exp. 06/30/2017)

Office of Housing

Federal Housing Commissioner

ALL PROGRAMS EXCEPT

SECTION 2062/8, SECTION 202 PAC,

SECTION 202 PRAC, AND

SECTION 811 PRAC

4, _-YES __ NO Is the above a person whose disability is based solely on any drug or

alcohol dependence (the person has no other disability which meets the

above definition).

NAME AND TITLE OF PERSON FIRM/ORGANIZATION

SUPPLYING THE INFORMATION

SIGNATURE DATE

Public reporting burden for this collection is estimated to average 12 minutes per response, including the time for reviewing

instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the

collection of information. This information is required to obtain benefits and is voluntary. HUD may not collect this information,

and you are not required to complete this form, unless it displays a currently valid OMB control number. Owners/management

agents must obtain third party verification that a disabled individual meets the definition for persons with disabilities for the

program governing the housing where the individual is applying to live. The definitions for persons with disabilities for programs

covered under the United States Housing Act of 1937 are in 24 CFR 403 and for the Section 202 and Section 811 Supportive

Housing for the Elderly and Persons with Disabilities in 24 CFR 891.305 and 891.505. No assurance of confidentiality is provided,

The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing

Act of 1937, as amended (42 U.S.C. 1437 et. seq.); the Housing and Urban-Rural Recovery Act of 1983 (P.L. 98-181);

the Housing and Community Development Technical Amendments of 1984 (P.L. 98-479); and by the Housing and

Community Development Act of 1987 (42 U.S.C. 3543).

APPENDIX 6-B 3 0f 4 form HUD-90103 (12/2007)

ref, HB 4350.3 Rev. |

SAMPLE VERIFICATION OF U.S. Department of Housing OMB Approval No. 2602-0204

and Urban Development (Exp.06/30/2017)

DISABILITY Office of Housing

Federal Housing Commissioner

ALL PROGRAMS EXCEPT

SECTION 202/8, SECTION 202 PAC,

SECTION 202 PRAC, AND

SECTION 811 PRAG

RELEASE: | hereby authorize the release of the requested information. Information obtained under this consent is

limited to information that is no older than 12 months. There are circumstances that would require the owner to verify

information that is up to 5 years old, which would be authorized by me on a separate consent attached to a copy of

this consent.

Signature Date

Note to Applicant/Tenant: You do not have to sign this form if either the requesting organization or the organization

supplying the information is left blank.

PENALTIES FOR MISUSING THIS CONSENT:

Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or

fraudulent statements to any department of the United States Government. HUD 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 this verification form is restricted to the purposes cited above.

Any person who knowingly or willingly 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 participant

affected 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 or the owner responsible for the unauthorized disclosure or improper use. Penalty

provisions for misusing the social security number are contained in the Social Security Act at 208 (a) (6), (7) and (8).

Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7) and (8).

f

BQUAL HOUSING

OPPORTUNITY

APPENDIX 6-B 4of4 form HUD-90103 (12/2007)

ref, HB 4350.3 Rev. 1