******OFFICE USE ONLY******

DO NOT WRITE IN THIS SPACE

Yakama Nation Housing Authority Rental
& Homebuyer Application

Please make sure your application has all of the items listed in the boxed area complete before submitting. Your application cannot be processed and will be considered incomplete without the following documents and verification:

Legal Name(s), physical and mailing address, and phone numbers.

Social Security #’s and Birthdates must be completed. Copies of Social Security cards for all listed are required.

Enrollment Verification or Proof of Ancestry. Copies of Enrollment cards or Certificate of Indian Blood/Proof of Descendancy from Enrollment office are required.

Report ALL INCOME for all 18 years of age and older or a signed Statement of Zero Income Verification of income must also be provided.

All 18 years and older need to sign their name on designated areas of the application, including the “Release of Information Form.”

If you are applying for the Homebuyer Waiting List and own land, a copy of your TSR (Title Status Report) is also needed to verify proof of land ownership.

Preference Information and Verification: If you feel that you qualify to receive a preference, please provide verification. You will not receive any of the preference points until verification is submitted. Preference Points are listed below:

  • Enrolled Yakama Head of Household (6pts)
  • Yakama Descendant Head of Household (5pts)
  • Enrolled Other Indian Head of Household (4pts)
  • Other Indian Descendant Head of Household (3pts)
  • Other Enrolled Yakama Household Member (3pts)
  • Elderly Person (60 yrs of age or older) (2pts)
  • Near Elderly Person (55-59 yrs of age) (1pt)
  • Veteran (1pt)

Screening: Your application will go through a screening process to determine eligibility. If and when your application nears the top of the waiting list, your application will be rescreened to confirm eligibility according to HUD regulations and YNHA Admissions and Occupancy Policies. If you are found ineligible, you will receive a “Disapproved Notice” in the mail. The screening process includes, but not limited to:

  • Total Household Income
  • Previous Tenant History
  • Custody Verification
  • Credit History
  • Criminal Background
  • Disability Status

PLEASE PRINT IN BLACK OR BLUE INK ONLY

I am applying for

Bedroom Size preferred (Homebuyer only):

This form MUST BE COMPLETED IN FULL. You must use the correct LEGAL NAME for each of your household members as it appears on their Social Security Card. Social Security cards & Enrollment verification must be submitted for all in your household. ALL ADULT MEMBERS OF THE HOUSEHOLD MUST SIGN ALL DESIGNATED AREAS & SUBMIT ALL INCOME VERIFICATION.

List all persons who will be occupying your home

Legal Name 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?

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 *VERIFICATION MUST BE SUBMITTED

Income Source Applicant Spouse Other Adult Other Adult
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$
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$
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$
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$
$
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$

“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.

*Does not apply to Enrolled Yakamas due to Gaming Revenue, unless verified by YN RAP Office.

ASSETS

Answer the following questions:

No Yes If yes, please explain (use additional of sheet if needed)
1. Do you or any household member own or have an interest in any real estate, boat and/or mobile home?
2. Do you have a savings account? If yes, give bank name & bank account amounts.
3. Do you own a car? License plate #: Make / Model /Year
4. Do you own a second car? License plate #: Make / Model /Year
5. 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?
6. Have you or any household member lived in any assisted housing? Where & When?
7. Have you or anyone in your household ever been convicted of any crime other than traffic violations? Where & When?
8. Have you or anyone in your household ever committed of fraud in any Federal or State Assisted Program or been requested to repay money for knowingly misrepresenting information for such programs? Where & When?

READ CAREFULLY, ALL ADULTS MUST SIGN THIS AREA

All adults 18 yrs of age and older must read carefully & sign:

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.

HOME BUYER WAITING LIST APPLICANTS MUST COMPLETE THIS SECTION

  • Do you have ownership of your own land?
  • Which of these does your land fall under?
  • Attach a copy of your TSR or your DEED of Land.

  • Did you inherit this land from another family member?
  • If yes, state your interest, or share amount entitled to you
  • If needed, will you be able to obtain a gift deed, long-term lease, partitionment, etc., to acquire sole-ownership of this land?
  • Town closest to location: Septic tank available?
  • Access Road:
    Electrical hook up:
    Telephone hook-up:

LANDLORD REFERENCES

List ALL the addresses where you have lived for your past 3 residences and the NAME, ADDRESS AND TELEPHONE NUMBER of the LANDLORD. Also, include the dates you rented from each landlord.

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 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