Fillable Housing Application Housing Application Form (Shoalwater Bay indian Tribe)

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Housing Application Housing Application Form (Shoalwater Bay indian Tribe)

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The Housing Application Housing Application Form (Shoalwater Bay indian Tribe) form is 3 pages long and contains:

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  • 12 check-boxes
  • 104 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Shoalwater Bay indian Tribe

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Date:
A.
Middle Initial:
State:
B.
Relationship
Family member name: to Applicant Date of Birth
1. Self
2.
3.
4.
5.
6.
7.
8.
C.
per
Family member name Rate (hour/month/etc.)
1.
2.
3.
D. No:
If "Yes", fill out Asset Information Form
Zip:
First Name:
(We must have a copy of a Social Security Card for every member of your family.)
City,State
City:
Phone Number(s):
SHOALWATER BAY INDIAN TRIBE HOUSING DEPARTMENT
Name
Employer/Source
Name
Address
LIST ALL MEMBERS OF YOUR HOUSEHOLD:
Home Location:
Mailing Address:
Housing Application
Social Security Number
Address
PRIMARY APPLICANT INFORMATION:
Last Name:
LIST ALL SOURCES OF INCOME:
Name
(Attach a copy of paystub, check or other verification.)
Address
City,State
City,State
Yes:
Such as: Bank accounts, Stocks, Rental Property, Individual Retirement Account, etc.
S:\Tenant Documents\Housing Application.xls Page 1 of 3
D.
1. Yes No
b. Do you receive Pension from Shoalwater Bay Tribe?
Yes No
2. Yes No
3. Yes No
Rate
4. Do you travel more than 60 miles round-trip to work? Yes No
Maximum for this allowance is $25 per week.
Signature of Applicant Date
Any other information or comments:
Information. (**You must sign a Care Provider Verification Form.)
Address
Name
If "Yes", you can deduct medical expenses you paid; you must provide receipts.
a. Are you over 62 years old?
Rate
Name
Address
City/State
Do you have childcare expenses?
I/We certify that the information given is accurate and complete to the best of my/our
knowledge and belief.
ADJUSTMENTS:
If you had to purchase auxiliary apparatus so a family member could work, you can deduct
the cost you paid; you must provide receipts.
City/State
If this person requires attendant care so a family member can work, list Care Provider
Is a household member Handicapped?
If "Yes", list Care Provider Information (**You must sign a Care Provider Verification Form.)
S:\Tenant Documents\Housing Application.xls Page 2 of 3
1. , Owner
Asset Information: Value:
Name of Bank/Business:
Address: Account No.:
City, State Zip:
2. , Owner
Asset Information: Value:
Name of Bank/Business:
Address: Account No.:
City, State Zip:
3. , Owner
Asset Information: Value:
Name of Bank/Business:
Address: Account No.:
City, State Zip:
4. , Owner
Asset Information: Value:
Name of Bank/Business:
Address: Account No.:
City, State Zip:
5. , Owner
Asset Information: Value:
Name of Bank/Business:
Address: Account No.:
City, State Zip:
6. , Owner
Asset Information: Value:
Name of Bank/Business:
Address: Account No.:
City, State Zip:
Fill in the name of the family member with the asset, and the address where we can verify the value.
SHOALWATER BAY INDIAN TRIBE HOUSING DEPARTMENT
Asset Information Form
S:\Tenant Documents\Housing Application.xls Page 3 of 3
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Housing Application Housing Application Form (Shoalwater Bay indian Tribe)

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Completed 20 July 2020

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