Low Rent Application (2018)

Low Rent Application

Saginaw Chippewa Housing

2451 Nish Na Be Anong

Mt. Pleasant, MI 48858

Phone: (989) 775-4532

Toll Free: (989) 1-800-894-9887

Fax: (989)775-4580

Please take this form with you and return it with all the documents that are

checked. These documents must be on file for your application to be correctly

processed.

____ Three landlord references and addresses from non-relatives

____ Three letters of reference from non-relatives

Documentation of income, pay stubs, or per capita stubs, etc.

____Copies of Social Security Cards for ALL family members.

Copies of Tribal Enrollment cards for all family members for documentation

of being Native American.

Documentation of homelessness, substandard living conditions or paying

50% or more of income for rent.

Documentation of assets.

Please be advised that you need to contact our office every ninety days to update

your application. If you do not contact us, you will be taken off the Waiting

List at the end of the ninety (90) days.

Provide a current (ICHAT) criminal history background check.

There is a $500.00 “security deposit” due at move in.

*Please note: All Housing units are smoke free — no smoking is allowed

within 25 feet of any unit or building.

Signature of Applicant:

Date:

Please return all applications to:

Saginaw Chippewa Housing

2451 Nish Na Be Anong

Mt. Pleasant, MI 48858

agencies, and schools and colleges and authorize the same to release information about me including,

but not limited to, information about my employment, my tenancy, and/or my Consumer credit history to

(1) any adverse action/decision is made based on the information in that report and

(2) if the request is made in writing within 60 days of the adverse action taken.

| believe, to the best of my knowledge, that all information | have Provided is accurate, true and correct

and that | fully understand the terms of this release.

Full Name

First Middle Last

Address

Street Address City State Zip

Date of Birth / / Social Security Number - -

Driver's License # State

Phone ( ) “e-mail address

Receive Text Messages? Yes or No I

Vehicle Plate

Company Requesting Information: Saginaw Chippewa Housing

2451 Nish-Na-Be-Anong Rd.

Mount Pleasant, MI 48858

Phone: (989) 775-4595 Fax: (989) 775-4580

Information Being Requested:

——_ Individual Credit Report ——oint Credit Report ———Social Security Verification

——Tenancy Verification & History — Employment Verification ——_Reference Check

—___Caseworker ACFS —___Caseworker BH —___Caseworker

Criminal History — Per Cap/Mno Information —___ Complete CEVAR form for admission

*This form with the authorizing signature will be kept on file and may be photocopied repeatedly

throughout the course Of its validation and used as needed.

Signature Date /

Staff: Date:

i ee

THINGS YOU SHOULD KNOW

Purpose

Don’t risk your chances for Federally assisted housing by providing false, incomplete or

inaccurate information on your application and recertification forms:

This is to inform you that there is certain information you must provide when applying

for assisted housing: There are penalties that apply if you knowingly omit information or

give false information.

Penalties for Committing Fraud

The United States Department of Agriculture, USDA Farmer’s Home Administration (FmHA)

places a high priority on preventing fraud. If your application or recertification forms contain

false or incomplete information you may be:

a Evicted from your apartment or house

a Required to repay all overpaid rental assistance you received

a Fined up to $10,000.00

a Imprisoned for up to 5 years, and/.or

a Prohibited from receiving future assistance.

Your State and local governments may have other laws and penalties as well.

Asking Questions

When you sit down with the person who goes over your application, you should know what is

expected of you. If you do not understand something, say so. That person can answer your

questions or find out the answer for you.

Completing the Application Form

When you give your answers to application questions, you must include the following

information:

a All sources of funds you and the members of your family receive in wages, disability,

welfare payments, alimony, social security, pensions, per capita, etc.

a Any money you receive in behalf of your children, including child support, social security for

children, etc.

a Income from assets, interest from savings accounts, credit unions, certificates of deposit or

dividends from stocks, bonds, etc.

a Earnings from a second job or a part time job, including tips

a Any anticipated income such as a bonus or pay raise you expect to receive

Assets

a All bank accounts, savings bonds, certificates of deposit, stocks, real estate, etc. that are

owned by you and any adult member of your family/household who will be living with you.

a Any business or asset you sold in the last two (2) years for less than its full value, such as

your home to your children.

Family Household Members

The names of all the people (adults and children) who will actually be living with you, whether

or not they are related to you.

Signing the Application

a Do not sign any form unless you have read it, understand it, and are sure everything is

complete and accurate.

a When you sign application and recertification forms, you are claiming that they are complete

to the best of your knowledge and belief. You are committing fraud if you sign a form

knowing that it contains false or misleading information.

a Information you give on your application will be verified by your housing agency. In

addition, Housing may do computer matches of the income you report with various Federal,

State or private agencies to verify that it is correct.

Recertification

You must provide updated information at least once a year. You are also required to report any

changes in income or family/household composition immediately. Be sure to ask when you must

recertify. You must report on recertification forms:

a All income changes, such as pay increases or benefits, change of job, loss of job, loss of

benefits, etc. for all adult family/household members.

a Any family/household member who has moved in or out.

a Allassets that you or your family/household member owns and any asset that was sold in the

last two (2) years for less than its full value.

Beware of Fraud

You should be aware of the following fraud schemes:

a Do not pay any money to move up on the waiting list.

Do not pay for anything not covered by your lease.

Get a receipt for any money you pay.

Get a written explanation if you are required to pay any money other than rent (such as

maintenance charges).

ooo

Reporting Abuse

If you are aware of anyone who has falsified an application, or if anyone tries to persuade you to

make false statements, report them to the Housing Manager. If you cannot report to the

manager, report to the Planning Office Director at 775-4014.

Date:

Signature

NOTE: Because of past problems with applications not being kept updated and to avoid

future problems, please notify the Housing Office if you move or your family

status changes. Without current information, you may be removed from the

waiting list.

NOTE: ALL INFORMATION IS SUBJECT TO VERIFICATION

Preferences are given for priority ranking on the waiting list: Please check one if needed. THIS

CANNOT BE PROCESSED WITHOUT WRITTEN VERIFICATION:

1 Involuntarily Displaced: Explain:

2 Substandard Housing: Explain:

3 50% Income for Rent: Explain:

APPLICANT

Applicant No. 1

Name:

Current Address:

City, State, Zip Code:

Home Phone: Work Phone:

Driver’s License Number:

Applicant No. 2

Name:

Current Address:

City, State, Zip Code:

Home Phone: Work Phone:

Driver’s License Number:

List Names, Addresses and Phone Numbers of two relatives or friends who generally know how

to contact you:

I, Name: Phone:

Address:

City, State, Zip Code:

2. Name: Phone:

Address:

City, State, Zip Code:

Household Composition and Characteristics: List the Head of Household and all other members

who will be living in the apartment. Give the relationship of each family member to the head of

household.

Member Name Relationship | Birth date | Sex_| Soc. Sec. No. | Tribal Affiliation

INCOME AND ASSET INFORMATION

INCOME

Family Member Name

Source and Type of Income

Annual

Income

ASSETS

Member Name

Bank

Account No.

Current Balance

LIST THE VALUE OF ALL STOCKS, BONDS, TRUSTS, PENSIONS,

CONTRIBUTIONS OR OTHER ASSETS

Please answer each of the following questions. For each “YES” answer, provide an

explanation:

1. Is any member of your household employed full time, part time or seasonally?

2. Does any member of your household expect to work for any period during the next

twelve months?

3. Does any member of your household work for someone who pays him or her in cash?

4. Is any member of your household on leave of absence from work due to lay off, medical,

maternity or military leave?

5. Does any member of your household now receive or expect to receive unemployment

benefits?

6. Does any member of your household now receive or expect to receive child support?

7. Is any member of your household entitled to receive child support that he/she is not now

receiving?

8. Does any member of your household now receive or expect to receive alimony

payments?

9. Is any member of your household entitled to alimony payments that he/she is not now

receiving?

10. Does any member of your household receive or expect to receive welfare assistance?

11. Does any member of your family receive or expect to receive Social Security Benefits?

12. Does any member of your family receive or expect to receive income from a pension or

annuity?

13. Does any member of your household receive regular cash contributions from

individuals not living in the unit or from agencies?

14. Does any member of your household receive income from assets including interest on

checking or savings accounts, interest and dividends from certificates of deposit, stocks or

bonds, or income from the rental of property?

15. Does any member of your household receive or expect to receive an earned income tax

credit?

16. Do you own a home or other real estate?

17. Have you sold a home or other real estate?

18. If yes, what ws the market value of the asset?

19. How much did you sell it for? $

PLEASE ANSWER EACH OF THE FOLLOWING QUESTIONS. FOR EACH “YES”

ANSWER, PROVIDE THE DETAILS:

EXPENSES

1. Do you pay for childcare which enables you or another family member to work or go to

school?

If yes, give name and address of childcare provider, weekly cost and name of the family

member enabled to work:

FAMILIES WITH HANDICAPPED MEMBERS

Do you pay for a care attendant or for any equipment for the handicapped member(s) of the

family necessary to permit that person or someone else in the family to work?

If yes, give name and address of the care attendant, weekly cost, and name of the family member

enabled to work:

ELDERLY FAMILIES ONLY NEED TO FILL OUT THIS PORTION

Ages 50-55 Near Elderly; 55 and over Elderly

Yes No

1. Do you have Medicare?

2. Do you carry your own insurance coverage?

3. If yes, Policy No.: Monthly Premium $

4. Do you receive medical assistance through the welfare department?

5. Do you have any outstanding medical bills, which you are now paying?

6. Do you expect to have medical expenses during the next 12 months?

7. If yes, give anticipated dollar amount: $

8. What is the nature of your expected medical expenses?

PLEASE PROVIDE THE NAME, ADDRESS AND PHONE NUMBER OF TWO

PERSONAL REFERENCES:

Name: Phone:

Address:

City, State, Zip Code:

Relationship to you:

Name: Phone:

Address:

City, State, Zip Code:

Relationship to you:

PLEASE PROVIDE THE NAME, ADDRESS AND PHONE NUMBER OF YOUR

PRIMARY PHYSICIAN AND SOCIAL SERVICE WORKER, IF APPLICABLE

Doctor’s Name: Phone:

Address:

City, State, Zip Code:

COMMENTS/ADDITIONAL INFORMATION:

Use an additional piece of paper if necessary

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APPLICANT CERTIFICATION

I/We certify that if selected to receive assistance, the unit I/we occupy will be my/our only

residence. I/we understand that the above information is being collected to determine my/our

eligibility. I/we authorize the owner/management to verify all information provided on this

application and to contact previous or current landlords or other sources for credit a d

verification information which may be released to appropriate Federal, State, Tribal or local

agencies. I/We certify that the statements made in this application are true and complete to the

best of my/our knowledge and beliefs. I/we understand that false statements or information are

punishable under Federal Law.

Signed: Date:

Head of Household

Signed: Date:

Spouse

Tribal Affiliation: Membership No.:

WARNING: Section 1001 of Title 10 of the U.S. Code makes it a criminal offense to make

false statements or misrepresentation to any Department or Agency of the United States s

to any matter within its jurisdiction.

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1. Tribal Affiliation of Head of Household:

2. Membership Number:

3. Or proof of Descendent

4. Does anyone live with you not listed on page 5?

5. Is the head or spouse handicapped or disabled?

If yes, explain

6. Is anyone else in the household handicapped/disabled?

7. Identify any special housing needs required as a result of handicap

CURRENT HOUSING STATUS

How many people live in your home now?___ How many bedrooms do you have?

Are you being evicted? If yes, explain:

Are you being displaced? If yes, explain:

What is your current rent? $

What are you paying monthly for electric and gas? $

Are you now living in subsidized housing (Section 8, Section 236, Section 221(d)(3) or Farmer’s

Home Subsidized payments?

What is the condition of your current housing: Standard Unsafe/Unsanitary No indoor

Plumbing or Kitchen? Currently Homeless (circle those that apply)

LIST TWO PRIOR LANDLORD REFERENCES

Note: You must have names, addresses and Phone Numbers and they must

NOT be related to you:

Current landlord: Phone:

Address:

City, State, Zip Code:

Previous Landlord: Phone:

Address:

City, State, Zip Code:

12

Authorization for Credit Check

Please print

Name:

Address:

City and State

Social Security #:

Date of Birth:

Phone #

By signing below, you hereby authorize Saginaw

Chippewa Housing Dept. to obtain a credit report for the

purpose of credit and budgeting assistance/Housing

assistance.

Signature

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SAGINAW CHIPPEWA HOUSING

2451 NISH-NA-BE-ANONG — MT. PLEASANT, MI 48858 (989) 775-4532

(989) 775-4580

Verification of Landlord Reference

is an applicant/tenant for housing assistance which is

subsidized through the U.S. Department of Housing and Urban Development. Federal

regulations require that in order for the household to be eligible, we must verify the household’s

income, expenses and other information using third party written verifications. The information

you provide will be used only for the purpose of determining the household’s eligibility for the

program and will be held in strict confidence. We are required to complete our verification

process in a short time period and would appreciate your prompt response to this request

for information.

I, the undersigned, do hereby authorize the release of the information requested to Saginaw

Chippewa Indian Tribe of Michigan, Housing Department in Mount Pleasant, Michigan.

Applicant/tenant Signature: Date:

(or see signed Authorization for the Release of Information)

Previous Address:

PLEASE PROVIDE THE FOLLOWING INFORMATION:

Did or does the tenant pay rent on time? () Yes ( )No

If no, please explain:

Does Tenant owe any money for rent? Amount owed $

Were there any problems with the tenant disturbing neighbors? ( ) Yes ( ) No

If yes, explain:

Length of tenancy: From To

Reason for moving:

Would you ever rent to this Tenant again?

Comments:

Date: Title: Phone:

Signature:

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

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

For Office Use Only: Initial Annual Interim Occupancy Specialist

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Asset Self-Certification

For households whose combined net assets are $50,000 or less. Complete only ONE form per household; include assets of children, except foster children. Also

exclude assets held by foster adults or live-in aides. Do not leave blanks. Use N/A if a box is not applicable.

Applicant / Tenant: Unit #:

1) oO I/we do not have any assets at this time. If checked, skip to #3 below. OR 2) Oo I/we have the following assets.

Non-Necessary Personal Property

Note: Be sure to include the value of any cash or other asset in a safe deposit box or any other means of storage.

* Cash value is market value minus cost to convert an asset to cash, such as broker's fees, settlement costs, outstanding loans, penalties for early withdrawal, etc.

Non-necessary personal property (examples RVs, ATVs, boats, antique cars, stamp collections, etc) Cash Value* Interest Annual Income

Description: $ $

Description: $ $

Type of Asset Cash Value* | Interest | Annual Income Type of Asset Cash Value* | Interest Annual Income

Money Market accounts

Cash on hand $ $ current balances $ $

Life Insurance current cash

Checking current balances {$ $ value (exclude term life) $ $

Cryptocurrency

Savings current balances $ $ (Bitcoin, etc.) $ $

Debit cards (not linked to Stocks/Bonds current

labove accounts) $ $ balance $ $

CD/Money Market current

Annuities current balances |$ $ balances $ $

Brokerage accounts current Trust accounts current

account balance balances (if under control of

(mutual funds, etc.) $ $ the household) $ $

Internet based assets

current balance Lump sums not included in

(Cash App, Venmo, PayPal, accounts listed (i.e.

|ApplePay, etc.) $ $ lottery/inheritance, etc.) $ $

Other | Description Vehicles not used for regular

transport. (RVs, Campers,

$ $ etc.) $ $

[A] Total cash value of non-necessary personal property: Li otal

Important Note | if the above total value [A] is $50,000 or less, it is not added into the Total Net Assets Section [E] below. However, total

income from non-necessary personal property above is added to total income [F] below.

Real Property

Description of property Cash Value Income

TD] Total

[C] Total real property value:]$ Income from ]¢

real prop:

| Total Net Assets and Income

[E] Tax Return. Have you received a tax return or refundable tax _

credit in the last 12 months that was deposited into an account listed $ Subtract sana te eee am total net

above? a] No | Yes, Value of credit |_—————> See formula for (E):

[F] Total Net Assets: (Total real property [C] + non-necessary personal $ [F] Total Asset }$

property [A] (if [A] exceeds $50,000) - [E] tax return/refundable credit) Income: [B]+[D]

3) (2) Yes [No Within the past two (2) years, I/we have sold or given away assets (including cash, real estate, etc.) for more than $1,000

below their fair market value (FMV). If “No”, sign & date below. If "Yes", complete # 4, then sign & date below.

4) Date of disposal 1: Difference FMV & Amt. Rcvd.: Date of disposal 2: Difference FMV & Amt. Rcvd.:

Under penalty of perjury, I/we certify that the information presented in this certification is true and accurate to the best of my/our knowledge. The undersigned

further understand(s) that providing false representations herein constitutes an act of fraud. False, misleading, or incomplete information may result in the

termination of a lease agreement.

Date Applicant/Tenant __ Date Applicant/Tenant _Date

PENALTIES FOR MISUSING THIS VERIFICATION

Title18, 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 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 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 42 U.S.C. 208 (f)(g) and (h). Violations of these

provisions are cited as violations of 42 U.S.C. 408 f, gand h.

Applicant/Tenant