# Otoe-Missouria Housing Department (2024) > Briefs, arguments, decisions, and more. URL: https://www.frixlaw.com/law-library/documents/tribal%3Aotoe_missouria%3A8753c723bcc18cdc ## Record - **Collection:** Tribal code - **Document type:** Tribal code ## Text 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 --- Source: Frix Law Library, https://www.frixlaw.com/law-library/documents/tribal%3Aotoe_missouria%3A8753c723bcc18cdc. Public record. Not legal advice.