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HOUSING PROGRAMS APPLICATION Pokagon Band of Potawatomi Department (Pokagon Band of Potawatomi Indians)

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Pokagon Band of Potawatomi
Department of Housing & Facilities
Page 1 of 7
HOUSING PROGRAMS
APPLICATION
Please complete the information requested below. If you need assistance completing this pre-application, please call the
Pokagon Band Department of Housing toll free 877-983-0385. Thank you!
1. APPLICANT INFORMATION
a. Last Name
b. First Name
c. Middle
Initial
d. Prior Last Name(s)
e. Tribal Enrollment Number
f. Street Address or P.O. Box City State Zip Code
g. Date of Birth
h.Cell Phone Number i.Alternate Number
j. Email
k. Social Security Number
l. Drivers License Number
□ Cell Phone □ E-mail □ Mail
What is your contact preference? (please check one above)
2. HOUSEHOLD COMPOSITION (IMPORTANT – YOU MUST LIST ALL HOUSEHOLD MEMBERS)
b.
Relationship
to Applicant
c.
Date
of
Birth
d.
Sex
e.
Age
f.
Enrollment #
g.
Social Security &
Drivers License
Number
h.
Present
Household
Member
Self / Applicant
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
i. Is there anyone in your household who is pregnant?
Yes No
If yes, please list their name and anticipated due date:
3. CRIMINAL HISTORY
a. Have you or any Household Member (13 years of age or older) ever been convicted of any of the
following:
(1) Violent criminal activity?
(2) Drug related criminal activity?
(3) Criminal sexual conduct, including any sex offense?
(4) Any other crime?
If yes, please explain:
Yes No
OFFICIAL USE ONLY
Pre-App #:_____________
RAP LTOP
HOP HLGP RRP WSIP
Pokagon Band of Potawatomi
Department of Housing & Facilities
Page 2 of 7
b. Are you or any member of your household presently on probation?
If yes, please explain:
Yes No
c. Are you or any member of your household presently on parole?
If yes, please explain:
Yes No
4. HOUSEHOLD INCOME
Please list below the annual income of each Household Member 18 years of age or older. If a Household Member has no
income, please list “no income”.
a. Name (Applicant first then spouse, if applicable)
b. Source(s) of Income / Employer(s)
c. Years
at Job
d. Amount
e. Total:
5. HOUSING HISTORY
a. Address
(Address, City, State, Zip Code)
b. Rent / Owned
c. Years of
Occupancy
d. Monthly
Payment
e. Eviction or
Foreclosure
Current Residence:
Rent Own
Yes No
Rent Owned
Yes No
Rent Owned
Yes No
Rent Owned
Yes No
Rent Owned
Yes No
6. GENERAL INFORMATION
a. Are you 18 years of age or older, or have you been emancipated by operation of law or court with the
legal capacity to contract?
Yes No
b. If you are not an enrolled Pokagon Band Tribal Member, do you have legal custody of at least one (1)
Pokagon Band Tribal Member who is a minor child?
If yes, please identify the minor child:
Yes No
c. How many Household Members are 17 years of age or younger? Number:
d. How many Household Members are Pokagon Band Tribal Members? Number:
Pokagon Band of Potawatomi
Department of Housing & Facilities
Page 3 of 7
e. Of those who will be residing with you, is one of them your spouse?
Yes No
f. Are you a veteran?
Yes No
g. Are you or any Household Members who are 18 years of age or older presently unemployed?
Yes No
If yes, please list each unemployed Household Member, and for each identify:
(1) the length of unemployment
(2) the reason for unemployment
(3) all current assistance
i. Have you received any kind of prior housing assistance from the Pokagon Band?
Yes No
If yes, please list assistance and approximate dates received:
j.Have you or any Household Member ever been evicted from a Band housing unit
for violation of a lease? If yes, please explain, including listing the date of eviction:
Yes No
k.Have you or any Household Member ever abandoned a Band housing unit without
terminating the lease? If yes, please explain, including listing the date of abandonment:
Yes No
l. Are you presently receiving any services or assistance from the Pokagon Band?
If yes, please list assistance and the dates received:
Yes No
m. Do you or any Household Member owe money to the Pokagon Band?
Yes No
If yes, please list amount, type of debt and whether the debt is delinquent:
n. Are you or any Household Member in the process of filing, considering filing for bankruptcy, or have
you ever filed for bankruptcy?
Yes No
If yes, please list when the bankruptcy was filed or when you plan to file and why:
Pokagon Band of Potawatomi
Department of Housing & Facilities
Page 4 of 7
o. Are you presently behind on payments for any kind of debt; or have you ever been behind on
payments; or have you ever not paid a debt (car payments, credit cards, medical bills, or other debts)?
Yes No
If yes, please list your unpaid and/or delinquent debts:
p. Have you applied for any type of loan or credit in the past year?
Yes No
If yes, please indicate the loan applied for and the outcome:
q. Would you consider your present credit to be less than good?
Yes No
If yes, please explain:
r. Are you the foster parent to any Pokagon Band Tribal Member who is a minor child?
Yes No
If yes, how many foster children are in your care:
s. Is there a major event in your life right now that is affecting your housing situation?
Yes No
If yes, please explain:
t. Are you or anyone in your Household in need of a home that is accessible to a person with disability?
Yes No
If yes, please explain accessibility needed:
u. Are you interested in living on Band-owned land?
Yes No
If no, where would you like to live?
Pokagon Band of Potawatomi
Department of Housing & Facilities
Page 5 of 7
v. Is there anything else you would like to share with us that may have an impact on your present or
future housing condition?
Yes No
If yes, please explain:
7. PROGRAMS
A number of Programs available through the Department of Housing. Below, please indicate all Programs of interest.
□ Rental Assistance Program
□ Lease to Own Program
□ Home Ownership Program
□ Home Loan Guarantee Program
□ Repair and Rehabilitation
□ Homeowner Repair Reimbursement Program
□ Homelessness Prevention
□ Additional Housing Services:
□ Home Inspection
IMPORTANT: This Application does not apply to the
following programs, which have a separate application:
• Pokagon Storage or Apartment Rentals
• Water and Sewer Improvement Program
Applications for the above programs are available at the
Department of Housing.
8. GENERAL PROVISIONS
A. Program Policy. The Tribal Council has approved a number of policies governing housing programs, including
but not limited to, the Eligibility, Admission and Occupancy Policy for All Programs (“Program Policy”), which
applies to the above listed programs (“Programs”).
B. Application. To apply for assistance under the Programs, the Applicant must complete and submit to the
Department of Housing this Application, along with all other required forms; excluding, however, the Student
Temporary Housing Assistance Program and the Water and Sewer Improvement Program, which have separate
applications. The Applicant, and all Household Members who are eighteen (18) years of age and older, must sign
this Application, along with all other required forms. Upon request, the Department of Housing will endeavor to
assist the Applicant in completing this Application, along with all other required forms.
C. Documentation. The Applicant, and any Household Member who is eighteen (18) years of age or older, must
provide the Department of Housing with all documentation and information requested by the Department of
Housing in connection with this Application, and all such documentation and information must be current and
accurate in all respects.
Pokagon Band of Potawatomi
Department of Housing & Facilities
Page 6 of 7
D. Household Needs Assessment. The Department of Housing may require the Applicant to complete a Household
Needs Assessment, which will assist in determining the Programs for which the Applicant is eligible.
E. Household Plan of Action. The Department of Housing may prepare a Household Plan of Action designed to
address barriers to achieving home ownership or safe and adequate rental housing. The Household Plan of
Action may require the Applicant and Household members to complete training and counseling, including but
not limited to, financial training, homebuyer training, and social services counseling.
F. Credit Check. The Department of Housing may obtain a credit history report in connection with this
Application. The Department of Housing will provide the Applicant with a courtesy copy of the credit history
report during any Household Needs Assessment meeting with the Department of Housing staff. The Applicant
hereby authorizes the Department of Housing to obtain a credit history report in connection with this
Application.
G. Background Check. Prior to admission into any Program, a background investigation may be conducted in
connection with this Application, and prior to admission into any Development, a criminal history check will be
conducted on all Applicants and Household members who are thirteen (13) years of age or older. The Applicant
hereby authorizes the Department of Housing to make inquiries and to acquire from all public and private
persons, entities and agencies all information deed necessary by the Department of Housing to complete this
Application or to determine initial or continued eligibility for any Program, including but not limited to,
information regarding credit, employment, housing, and criminal history.
H. Failure to Provide Information. If the Applicant, or any Household Member who is eighteen (18) years of age or
older, fails to provide the Department of Housing with the necessary eligibility information, this Application will
be placed on hold until such time as the necessary documentation is provided. If this Application is on hold for
more than thirty (30) calendar days, it will be closed and the Applicant will be removed from any waiting list.
I. Notice of Eligibility or Ineligibility. The Department of Housing will send the Applicant notice within seven (7)
calendar days of certifying the Applicant as eligible or ineligible. Any notice of ineligibility will describe the basis
for the determination and the right to file an Appeal in accordance with Article 22 of the Program Policy.
J. Waiting List. The Department of Housing will maintain a separate waiting list for each Program that is full. As a
condition of remaining on the waiting list, the Applicant must (1) respond to all written, update requests from the
Department of Housing, including but not limited to updating this Application annually; and (2) update this
Application to reflect any change in the number of Household Members. If the Applicant fails to update this
Application within thirty (30) calendar days from the date of mailing of any update request, the Applicant will be
removed from the waiting list and this Application will be closed.
K. Recertification. The Department of Housing will recertify the eligibility of all Applicants on a waiting list prior
to participation in a Program, including but not limited to, occupancy of any housing unit. The Applicant must
continue to satisfy all eligibility requirements while participating in a Program.
L. Assistance Agreement. Prior to the expenditure of funds or occupancy under any Program, the Applicant must
enter into an Assistance Agreement with the Pokagon Band. All Household members, who are who are eighteen
(18) years of age and older, must sign the Assistance Agreement. In lieu of an Assistance Agreement, a lease must
be signed for the Lease to Own Program and the Transitional Housing Assistance Program. Also, an Assistance
Agreement with the Pokagon Band is not required for the Water and Sewer Improvements Program.
M. Fair and Impartial. Tribal Council and the Department of Housing staff must be fair and impartial, at all times
and in all respects, in selecting people to participate in Programs, including but not limited to, determinations
relating to eligibility, admission, and occupancy of Housing Units. No elected official or employee of the
Pokagon Band shall make any determination based in whole or in part on family ties, political views, or personal
bias.
Pokagon Band of Potawatomi
Department of Housing & Facilities
Page 7 of 7
N. No lobbying. No person shall attempt to influence the process for admission into any Program by lobbying staff
of the Department of Housing or the Tribal Council. The Applicant must utilize the Appeal procedures set forth
in Article 22 of the Program Policy, as applicable.
O. Appeals. An Applicant, who is adversely affected by action or inaction of the Department of Housing in
connection with the Programs, or who is certified as ineligible for any Development, has the right of appeal in
accordance with Article 22 of the Program Policy.
P. Tax Agreement Area. The Applicant must reside in the Pokagon Band tax agreement area to be eligible for
certain types of tax benefits as a Pokagon Band Member. The Applicant must contact the Pokagon Band Finance
Department to obtain information on tax agreement benefits.
Q. Conflict. The foregoing is intended to summarize provisions of the Program Policy. Accordingly, in the event of
any conflict between the Program Policy and any provision of this Application, the Program Policy shall control.
The undersigned Applicant and Household Members (who are 18 years of age and older) hereby certify that all
information stated in this Application, or provided to the Department of Housing in connection with this Application, is
complete, accurate and truthful in all respects and acknowledge that if any false or misleading information was provided,
the Band retains the right to reject this Application, discontinue all assistance, and to exercise or pursue all available
remedies, including but not limited to, referral for prosecution.
Applicant
______________________________ _____________________________ _________________
Print Signature Date
Household Member
______________________________ _____________________________ _________________
Print Signature Date
Household Member
______________________________ _____________________________ _________________
Print Signature Date
Household Member
______________________________ _____________________________ _________________
Print Signature Date
Household Member
______________________________ _____________________________ _________________
Print Signature Date
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HOUSING PROGRAMS APPLICATION Pokagon Band of Potawatomi Department (Pokagon Band of Potawatomi Indians)

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Completed 20 July 2020

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