ANNUAL RECERTIFICATION

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.

PLEASE PRINT IN BLACK OR BLUE INK ONLY

List all persons who are occupying your home:
Head of Household Date of Birth Relationship to Head of Household Tribal Affiliation & Enrollment Number Social Security # Place of Birth
1
2
OTHERS
3
4
5
6
7
8
9
10
Are you or any other adult (18 yrs or older) an enrolled full-time student? Yes or No
If yes, please list names and provide documentation of enrolled full-time student status:

TOTAL HOUSEHOLD INCOME

MUST BE COMPLETED FOR ALL 18 YRS OF AGE & OLDER

IF EMPLOYED or SELF EMPLOYED, PLEASE COMPLETE THIS SECTION & SUBMIT VERIFICATION

Household Member Occupation / Job Title Employer Pay Schedule (weekly, bi-weekly or monthly) Hours Per Week Hourly Rate Tips or Commission

OTHER HOUSEHOLD INCOME *VERIFICATIN MUST BE SUBMITTED*

Income Source Head of Household Spouse Other Adult Other Adult

“Statement of Zero Income”

If there are any adults 18 yrs of age or older that do not receive any type of income, he/she must sign this statement.

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.

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.

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.

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.

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
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.

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

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.

Original is retained by the requesting organization.

Form HUD 9886 (4/91) ref. Handbooks 4350.3, 7420.7, 7465.1

Deductions

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