Form no. 04021HIG CS-HOU Rev. 2/2017
The CHICKASAW NATION HOUSING DIVISION
111 Rosedale Road/P. O. Box 788/Ada, Oklahoma 74821-0788
(580) 421-8800/Fax; (580) 559-0720
REQUEST FOR RELEASE OF INFORMATION
Applicant: Date:
First Middle Last Suffix
Address: Phone:
City: STATE: ZIP:
In applying for the grant, I completed an application containing various information on the
purpose of the grant, with employment and income information. I certify that all of the information is
true and complete. I made no misrepresentation in the application or other documents, nor did I omit
any pertinent information.
I hereby give my consent for information contained in the application and in other documents
required in connection with the grant, either before the grant is approved or as part of its quality
control program, to be verified or re-verified. This verification or re-verification may be made by the
Chickasaw Nation Housing Division, its agent, successors and/or assigns. Such information includes,
but is not limited to, employment verification and copies of income tax returns and/or W-2 forms.
Photographic or carbon copies of the signatures(s) of the undersigned may be deemed to be
equivalent to the original and may be used as a duplicate original.
Applicant signature Date Social Security #
Spouse signature Date Social Security #
Other adult member Date Social Security #
