Annual Re-certification

For Low Rent/NAHASDA Tenants only, does not apply to Tax Credit Rental Tenants for Self Certifications (SCAI) or Resident Eligibility (REA) paperwork.

This form MUST BE COMPLETE IN FULL. You must use the correct LEGAL NAME for each of your household members as it appears on the Social Security Card. ALL ADULT MEMBERS OF THE HOUSEHOLD MUST SIGN ALL DESIGNATED AREAS & SUBMIT ALL INCOME DOCUMENTATION. Social Security Cards & Enrollment Verification must be provided for all household members.

*Indicates a required field

Head of Household

First Name:* Last Name:* Physical Address:* Address 2: City:* State:* Zip:* Mailing Address (if different than physical address): Address 2: City: State: Zip: Home Phone: Cell Phone:* Work Phone: Message Phone: Email Address:*

List all persons who are occupying your home

If a signature is required and no email address is provided, that signature will need to be done in person.

Head of Household

First Name: Last Name: Date of Birth (mm/dd/yyyy) Place of Birth Tribal Affiliation & Enrollment Number Email Address:

First Name: Last Name: Relationship to HOH Date of Birth (mm/dd/yyyy) Place of Birth Tribal Affiliation & Enrollment Number Email Address:

Others

First Name: Last Name: Relationship to HOH Date of Birth (mm/dd/yyyy) Place of Birth Tribal Affiliation & Enrollment Number Email Address:

Education Status

Are you or any other adult (18 yrs or older) an enrolled full-time student? If yes, please list names and provide details of enrolled full-time student status (additional documentation may be required)

Total Household Income

MUST BE COMPLETED FOR ALL 18 YRS OF AGE & OLDER. IF EMPLOYED or SELF EMPLOYED, PLEASE COMPLETE THIS SECTION & SUBMIT VERIFICATION

First Name: Last Name: Employer Pay Schedule Hours Per Week Hourly Rate Tips or Commission

OTHER HOUSEHOLD INCOME VERIFICATION MUST BE SUBMITTED

Unemployment Benefits Labor & Industry Benefits Retirement/Pension Benefits Veteran’s Benefits Social Security Benefits Social Security Income (SSI) Child Support or Alimony Lease Income AFDC / TANF General Assistance Other Income (Please explain)

Statement of Zero Income

If there is an adult 18 yrs or older who does not receive any type of income they must sign a “Statement of Zero Income” by entering your name below.

I do not have any income. This includes earning from employment, payments from any public assistance program (DSHS/GA) unemployment benefits, social security benefits or SSI payments, lease income, babysitting or any other type of income. I understand that I must report any changes of my income status immediately to YNHA. I also understand that knowingly providing false or inaccurate information is punishable under Federal, State or Tribal Criminal Law.

Assets

Do you or any household member own or have an interest in any real estate, boat and/or mobile home? If yes, please explain

Do you have a savings account? If yes, give bank name & bank account amounts. If yes, please explain

Do you own a car? License plate # / Make / Model / Year

Do you own a second car? License plate #, Make / Model /Year

Have you or any other adult members ever used any name(s) or social security number(s) other than the one you are currently using? If yes, please explain

Have you or any household member lived in any assisted housing? Where & When?

Have you or anyone in your household ever been convicted of any crime other than traffic violations? Where & When?

Have you or anyone in your household ever committed a fraud in any Federal or State Assisted Program or been requested to repay money for knowingly misrepresenting information for such programs? Where & When?

Deductions

If you feel that you may qualify for any of the following deductions, ask your Resident Services Specialist (RSS) for more information.

Is there an adult who is a full time student in your household? Do you pay child care for a child age 13 or younger while you are at work or school? Do you travel 14 miles per day for work or school? Do you pay out-of-pocket Medical and Attendant expenses?

Upload Documents

30MB total maximum file size limit. If your files are too large please email them to [email protected].

Please do not send sensitive data such as Social Security Numbers through this form or via email.

Household Income Verification Enrollment Verification School Enrollment Documentation Other Current Household Income Verification

Authorization for the Release of Information

U.S Dept. of Housing & Urban Development
Office of Housing
Office of Public and Indian Housing

PHA requesting release of information: (Name, Address & Phone Number)YAKAMA NATION HOUSING AUTHORITY
P.O. BOX 156
WAPATO, WA 98951
(509) 877-6171

Purpose:

The U.S. Department of Housing and Urban Development (HUD) and the above named organization may use this authorization and the information obtained with it, to administer and enforce program rules and policies

Authorization:

I authorize the release of any information (including Law Enforcement Agencies documentation and other materials) pertinent to eligibility for Credit Bureaus or participation under any of the following programs:

Low-Income Rental Indian Housing
Low-Income Rental Public Housing
Mutual Help Homeownership Opportunity Program
Rental Assistance Program (RAP)
Rent Supplement
Section 8 Housing Assistance Payments Program
Section 23 and 10 ( C ) Leased Housing
Section 23 Housing Assistance Payments
Section 202
Section 221(d)(3) Below market Interest Rate
Turnkey III Homeownership Opportunities Program

I authorize the above named organization and HUD to obtain information about me or my family that is pertinent to eligibility for or participation in assisted housing programs.

I authorize only HUD, an Indian Housing Authority, or a Public Housing Agency to obtain information on wages or unemployment compensation from State Employment Securities Agencies.

Information Covered Inquiries may be made about:

Child Care Expenses
Credit History
Criminal Activity
Family Composition
Employment, Income, Pensions, and Assets
Federal, State, Tribal, or Local Benefits
Handicapped Assistance Expenses
Identity and Marital Status
Medical Expenses
Social Security Numbers
Residences and Rental History

This form can not be used to request a copy of a tax return. Instead, use IRS Form 4506, Request for Copy of TAX Form.

Individuals Or Organizations That May Release Information:

Any individual or organization including any governmental organization may be asked to release information. For example, information may be requested from:

Banks and Other Financial Institutions
Courts
Law Enforcement Agencies
Credit Bureaus
Employers, Past and Present
Landlords

Provider of:

Alimony
Child Care
Child Support
Credit
Handicapped Assistance
Medical Care
Pensions/Annuities
Schools and Colleges
U.S. Social Security Administration
U.S. Department of Veterans Affairs
Utility Companies
Welfare Agencies, Chemical Dependency Programs

Computer Matching Notice & Consent:

I agree that a Public Housing Agency, Indian Housing Authority, or HUD may conduct computer matching programs with other governmental agencies including Federal, State, Tribal, or local agencies. The governmental Agencies include:

U.S. Office of Personnel Management
U.S. Social Security Administration
U.S. Department of Defense
U.S. Postal Service
State Employment Security Agencies
State Welfare and Food Stamp Agencies

The match will be used to verify information supplied by the family

Conditions:

I agree that photocopies of this authorization may be used for the purposes stated above.

If I do not sign this authorization, I also understand that my housing assistance may be denied or terminated.

I do hereby swear and attest that all of the information given about me and my household is true and correct. I also understand that ALL CHANGES in the income of any household member as well as ANY CHANGES in the household members must be reported to the Housing Authority in writing immediately.

I also agree that I know that I am required to cooperate in supplying all information needed to determine my eligibility, level of benefits, or verify my true circumstances. Cooperation includes attending pre-scheduled meetings and completing and signing needed forms. I understand failure or refusal to do so may result in delay, termination of assistance, eviction and or disapproval of my application, termination of my Low Rent Lease or Termination of my MHOA.

I also understand that knowingly providing false, incomplete or inaccurate information is punishable under Federal, State, or Tribal criminal law. I understand that knowingly giving false, incomplete, or inaccurate information is grounds for immediate termination.

Signatures

Enter Name of Head of Household* Enter Name of Other Adult Member of the Household* Enter Name of Other Adult Household Member* Enter Name of Other Adult Member of the Household*

Original is retained by the requesting organization. Form HUD 9886 (4/91) ref. Handbooks 4350.3, 7420.7, 7465.1

Annual Re-Certification

Head of Household

List all persons who are occupying your home

Head of Household

Others

Education Status

Total Household Income

OTHER HOUSEHOLD INCOME VERIFICATION MUST BE SUBMITTED

Statement of Zero Income

Assets

Deductions

Upload Documents

Authorization for the Release of Information

Purpose:

Authorization:

Information Covered Inquiries may be made about:

Individuals Or Organizations That May Release Information:

Provider of:

Computer Matching Notice & Consent:

Conditions:

Signatures

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