Fillable Chickasaw Nation Housing - CHIP/STORM SHELTER Application (The Chickasaw Nation)

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Chickasaw Nation Housing - CHIP/STORM SHELTER Application (The Chickasaw Nation)

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Form no. 04852CMSSCL CS-HOU Rev. 4/2016
Dear Applicant:
You have requested CHIP/STORM SHELTER services and we are pleased to provide you this
application. Applications must be completed and returned with all required documents before eligibility can
be determined. Incomplete applications will not be processed and may be mailed back to you.
Documents required are:
Completed and signed application.
All persons 18 years and older –
(1) Sign and date Release of Information and
(2) Privacy Act
Signed Conflict of Interest Disclosure.
Current income verification for all adult members of the household who are employed.
(Employment verification must be completed by employer)
If self-employed attach copies of the past two years Federal Income Tax Return. (signed and dated)
Copy of current year award letter for social security or disability recipient.
Other Income: VA, retirement, child support, unemployment or other source must be verified by
agency.
Copy of Warranty Deed showing proof of ownership.
Copy of CDIB Card (which shows your degree of blood) and/or Citizenship card.
Copy of social security cards for all household occupants.
Copy of driver’s license (picture ID)
We look forward to providing you with this service. If we can be of assistance to you in completing
the application, you may contact our office at (580) 421-8800.
Sincerely,
Admissions Specialist
Housing Management Services
Enclosures
Form no. 04852CMSSP CS-HOU Rev. 4/2016
THE CHICKASAW NATION HOUSING DIVISION
HOUSING IMPROVEMENT PROGRAMS
STORM SHELTER PROGRAM
This program provides storm shelters for privately owned homes of Chickasaw citizens.
CHICKASAW HOUSING IMPROVEMENT PROGRAM
Provides rehabilitation of older housing units and grants for repair of privately-owned homes of
low income (80% or lower U.S. Median Income) Native Americans and emergency repairs of
privately-owned homes of Chickasaw citizens.
Program requirements:
• Native American preference
• Low income
Applications must be updated annually.
Priority for CHIP: Priority 1 All Chickasaw Citizens
Priority 2 All other Native Americans
Additional preference is given to families that are first time applicants, elderly, disabled or
Veterans.
Page 1 of 2 Form no. 04852CMSS CS-HOU Rev. 5/2016
PLEASE CHECK ALL PROGRAMS THAT MAY APPLY:
Storm Shelter CHIP Minor
Applicant name:
Address:
City/state/ZIP:
Telephone: ( ) Work phone: ( )
Family composition - complete the information below for all family members who are living in your home:
Name of family
member
Birth
date
Sex
Relationship to
head of household
Age
Type of
income
Employer
Head of household
Is any member of your household handicapped or disabled? Yes No
Is any member of your household a Veteran? Yes No
Additional Income Information
Does any member of your household attend college or vo-tech? Yes No Receive grants? Yes No
List type of grant and amount:
Does any member of your household receive cash contributions from individuals not living with you? Yes
No $ / per week/month.
Does any member of your household receive child support? Yes No If yes, list amount: $
Family Assets Information
Does any member of your household have a checking/savings account? Yes No
Bank name: Address: Account #:
Bank account balance: $
Does any member of your household receive income from interest or dividends from certificates of deposit,
stocks or bonds?
Yes No
If yes, list name and address of institution from which you purchased such:
Monetary value: $
the
Chickasaw Nation
Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Bill Anoatubby
Governor
Page 2 of 2 Form no. 04852CMSS CS-HOU Rev. 5/2016
Have
you disposed of assets within the last two year (e.g.: land, house, money, automobile, etc.)? Yes No
If yes, please provide proof and value of said asset: $
Does any member of your household own interest and receive revenue checks from oil or gas wells? Yes
No
If yes, give monthly amount? $ Name and address of company:
Do you currently owe the Chickasaw Nation Housing Division any outstanding balance? Yes No

***The following section is for CHIP Minor applicants only***
Have you ever received previous CHIP services? Yes No Is the property a mobile home? Yes No
What is the age of the property? ________ List of needed improvements

Ethnic group (statistical purpose only)
1. White, not of Hispanic origin 2. Black, not of Hispanic origin 3. American Indian or Alaskan
Native
4. Hispanic 5. Other Tribal affiliation:

I understand that the above information is being collected to determine my eligibility for housing services.
Information given will be verified and may be released to appropriate federal, state or local agencies. I certify
that the statements in this application are true and complete to the best of my knowledge and belief. I
understand that incorrect information or false statements are punishable under federal law.
Signature of head of household: Date:
Signature of spouse: Date:
Form no. 04852RoI CS-HOU Rev. 4/2016
Request for Release of Information
Family/individual: Date:
Address:
City: State: ZIP:
You are requested to provide the Chickasaw Nation Housing Division any information from
your records which is needed by the division of housing in determining eligibility for the above
named participant/tenant and his/her family.
Your cooperation and prompt return of the information will be appreciated and this
information will be held in confidence and used only by the division of housing as legally
permissible.
I give my permission for you to release this requested information to the Chickasaw Nation
Housing Division.
Signature of head of household Social Security number
Signature of spouse Social Security number
Signature of other adult member Social Security number
Signature of other adult member Social Security number
Bill Anoatubby
Governor
the
Chickasaw Nation
Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Form no. 04852UPA CS-HOU Rev. 4/2016
Privacy Act Notice
The Chickasaw Nation Housing Division is authorized to collect information by the Native
American Housing Assistance and Self Determination Act of 1996 (NAHASDA). You must provide
all of the information requested by the housing division, including all Social Security numbers you
and all other household members age six years and older have and use.
Your income and other information are being collected by the division of housing to determine
your eligibility, the appropriate bedroom size and the amount your family will pay toward rent. This
information may be released to appropriate federal, state and local agencies when relevant and to
civil, criminal or regulatory investigators and prosecutors pursuant to federal law.
The information will not be otherwise disclosed or released except as permitted or required by
law. Failure to provide any of the requested information may result in a delay or rejection of your
eligibility approval.
Head of household Date
Spouse Date
Other adult member Date
Other adult member Date
the
Chickasaw Nation
Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Bill Anoatubby
Governor
Form no. 04852CID CS-HOU Rev. 4/2016
Conflict of Interest Disclosure
The Chickasaw Nation Housing Division takes seriously any actual or potential conflicts of
interest. As we wish to avoid even the appearance of a conflict, we ask all applicants to
disclose any immediate family members, or other significant persons, which could potentially
cause a conflict of interest. For this purpose, immediate family member includes, but is not
limited to, spouse, children, parents and siblings.
Please list any relationship here (please print):
Attestation: The undersigned individual(s) hereby attest(s) that he/she is a participant in one
or more of the housing division programs and that he/she is independent of and has no conflict
of interest with any persons not listed above.
Signature of head of household Date
Signature of spouse Date
FOR DIVISION USE ONLY:
CURRENT HOUSING SITUATION PRIOR TO ASSISTANCE
OVERCROWDED SUBSTANDARD
ELDERLY/SUBSTANDARD HOMELESS
DISABLED STUDENTS ASSISTED WITH
RENTAL TO OWNER HIGHER EDUCATION
Bill Anoatubby
Governor
the
Chickasaw Nation
Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Form no. 04852UBV CS-HOU Rev. 5/2016
Banking Verification
Applicant/tenant: Date:
Address: Social Security number:
Social Security number:
Account number:
I hereby grant the Chickasaw Nation Housing Division permission to make inquiries regarding my
income and assets. I understand that this information will be kept confidential.
Applicant/tenant signature

**TO BE COMPLETED BY YOUR BANKING INSTITUTION**
Current checking account balance:
Interest rate paid:
Interest received in the past 12 months:
Current savings account balance:
Interest rate paid:
Interest received in the past 12 months:
Amount of savings certificates:
Interest rate paid:
Interest received in the past 12 months:

Name of institution:
Address: Phone: ( )
By: Title: Date:
Housing representative
the
Chickasaw Nation
Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Bill Anoatubby
Governor
Form no. 04852UEV CS-HOU Rev. 4/2016
EMPLOYMENT INCOME VERIFICATION
Employee name: Date:
Employee address: Soc. Sec. no.:
The Chickasaw Nation Housing Division is required to verify the income of all applicants/tenants/participants of
the programs. The person named above states that he/she is now employed by your firm. Your cooperation in
supplying the information requested below will be appreciated and of benefit to your employee. Such
information will be held in confidence and used only by the housing division as legally necessary.
Date Housing division representative
I hereby authorize the release of this information to the Chickasaw Nation Housing Division.
Date Employee signature
INFORMATION BELOW IS TO BE COMPLETED BY EMPLOYER ONLY!
******************************************************************************************************************************
1. Date of employment:
2. Occupation:
3. Employment is: Permanent: Temporary: Part-time: Seasonal:
If seasonal or temporary, please explain:
4. Current average number of hours worked per week: Straight time: Overtime:
5. Current base pay rate: $ per: Date effective:
6. Expected change in rate of pay (date):
New base pay rate: $ per:
7. If overtime rate is paid, at what rate is it paid: $ __________________________
8. Amount of bonus, incentive pay, commission and/or tips: $ per:
9. If seasonal or sporadic employment, give lay-off periods:
10. Does this employee receive vacation with pay? Sick leave with pay?
11. Amount deducted for medical/hospital insurance: $ per:
Weekly, bi-weekly, monthly
12. Amount deducted for child support: $ per:
Weekly, bi-weekly, monthly
13. Anticipated total earnings for next 12 months: $
The above information is true and correct to the best of my knowledge. I understand that any false
statements of information are punishable under federal law.
Date: By:
Firm name: Title:
Address: Phone: ( )
the
Chickasaw Nation
Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Bill Anoatubby
Governor
Form no. 04852ZI CS-HOU Rev. 5/2016
Zero Income Verification
This form is to be completed by all adults living in the household who do not have income.
Answer the questions below either no or yes.
I, , do certify that I do not have income from any source:
Include the following:
No Yes - Income from performing odd jobs (yard maintenance, house cleaning, baby-sitting, etc.)
No Yes – Income received from relatives or friends to aid in maintaining my household.
No Yes – Income received from child support or alimony.
No Yes – Income from unemployment, Social Security, welfare (DHS), Veterans Administration
or Workers Compensation.
$ - Income from grants and scholarships.
$ - Income received from employment or retirement.
**PLEASE STATE HOW YOU PAY FOR EVERYDAY EXPENSES (RENT, UTILITIES, FOOD, ETC.)**
Should my income status change, I will notify the Chickasaw Nation Housing Division immediately so that
proper verification can be obtained.
I acknowledge that any misrepresentation of income, assets or family composition used from my application
to determine eligibility may result in termination of participation in the program, or I may be required to pay
the difference between the total tenant’s payment paid and the amount which should have been paid.
Signature of applicant/tenant Date
Housing division representative Date
the
Chickasaw Nation
Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Bill Anoatubby
Governor
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Chickasaw Nation Housing - CHIPSTORM SHELTER Application (The Chickasaw Nation)

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Completed 31 January 2021

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