BIA Form 6407 OMB Control No. 1076-0184
ISSUED 01/01/2019 EXPIRATION DATE: 02/28/2022
Date of this application: ______________________
G. APPLICANT CERTIFICATION ______________________________________________________
(Read this certification carefully before you sign and date your application. Sign in ink).
I certify that all the answers given are true, complete and correct to the best of my knowledge and
belief, and they are made in good faith. This certification is made with the knowledge that the
information will be used to determine eligibility to receive financial assistance, and that false or
misleading statements may constitute a violation of 18 U.S.C. 1001.
This application contains material covered by the Privacy Act. No record will be communicated to
anyone or any agency unless requested in writing, by the applicant, or unless an officer or employee of
the housing program or other Federal agency requires it in the performance of their duties.
Applicant's Signature: ______________________________________ Date: __________________
Spouse's Signature: ________________________________________ Date: __________________
PRIVACY ACT STATEMENT
25 CFR 265 and 25 U.S.C. 13 authorize the collection of this information. This information is covered by the
system of record notice "Indian Housing Improvement Program, Interior, BIA-10." The primary use of this
information is to determine eligibility for assistance under the Housing Improvement Program. The records
contained therein may only be disclosed in accordance with the routine uses and may not otherwise be
disclosed by any means of communication to any person, or to another agency, except pursuant to a written
request by, or with prior written consent of the individual to whom the record pertains. If the BIA uses the
information furnished on this form for purposes other than those indicated above, it may provide you with an
additional statement reflecting those purposes. Executive Order 9397 authorizes the collection of your Social
Security number. Furnishing the information is voluntary but failure to do so may result in disapproval of
PAPERWORK REDUCTION ACT STATEMENT
This information is being collected to select eligible families or individuals to participate in the Housing
Improvement Program. Response to this request is required to obtain a benefit in accordance with 25 CFR
256. You are not required to respond to this collection of information unless it displays a currently valid
OMB control number. This information will be used to determine the eligibility and the ranking of the
applicant. Public reporting burden for this form is estimated to average 1 hour per response, including the
time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form.
Direct comments regarding the burden estimate or any other aspect of this form to Information Collection
Clearance Officer - Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.
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