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

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


Education Status

Total Household Income


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.



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

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.

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


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


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


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.


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

Contact Us

611 South Camas Ave.
Wapato, WA 98951

Phone: 509-877-6171
Fax: 509-877-7830

Office Hours

Open: Monday - Friday
Hours: 8:00am – 4:30pm

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