Today's Date *

MM

DD

YYYY

Housing Program *

Rental Assistance

Applicant Name *

First Name

Last Name

Home Phone *

(###)

###

####

Cell Phone

(###)

###

####

Landlord/Mortgage Company Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Landlord/Mortgage Company Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Landlord/Mortgage Company Phone *

(###)

###

####

Check One *

Own

Rent

Share

Homeless

Other

Name Family Member 1

First Name

Last Name

Full Time Student

Yes

No

Name Family Member 2

First Name

Last Name

Full Time Student

Yes

No

Name Family Member 3

First Name

Last Name

Full Time Student

Yes

No

Name Family Member 4

First Name

Last Name

Full Time Student

Yes

No

Name Family Member 5

First Name

Last Name

Full Time Student

Yes

No

Name Family Member 6

First Name

Last Name

Full Time Student

Yes

No

Does any household member have any needs that might be better served by a unit which is accessible to persons with mobility, hearing or visual impairments? *

Yes

No

Are you or any member of your household subject to a lifetime sexual offender registration? *

Yes

No

Has any family member of the household residing with you served in the military? If yes, who? *

Yes

No

Do you or anyone in your household own any other real property? *

Yes

No

Are you currently homeless

Yes

No

Emergency Contact Name *

First Name

Last Name

Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Phone *

(###)

###

####

Appliction Certification *

I/We understand the information provided above is obtained to determine if I/We are eligible to receive Housing Program assistance. I/We hereby certify that all the information provided herein is true and correct. I/We understand that providing false statements or information is grounds for termination of housing assistance and is punishable under tribal law and/or I forfeit my eligibility to apply for services in the future for up to 10 years. I further understand that if I am deemed eligible, I cannot apply for services within 24 months of receiving funding from the Housing Department.

Applicant Acknowledges