Fillable NATIVE VILLAGE OF BARROW IUPIAT TRADITIONAL GOVERNMENT (Native Village of Barrow)

Fill Online, Printable, Fillable, Blank NATIVE VILLAGE OF BARROW IUPIAT TRADITIONAL GOVERNMENT (Native Village of Barrow) Form

Use Fill to complete blank online NATIVE VILLAGE OF BARROW (AK) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

NATIVE VILLAGE OF BARROW IUPIAT TRADITIONAL GOVERNMENT (Native Village of Barrow)

On average this form takes 74 minutes to complete

The NATIVE VILLAGE OF BARROW IUPIAT TRADITIONAL GOVERNMENT (Native Village of Barrow) form is 16 pages long and contains:

  • 12 signatures
  • 19 check-boxes
  • 241 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Native Village of Barrow

BROWSE NATIVE VILLAGE OF BARROW (AK) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
NATIVE VILLAGE OF BARROW
IÑUPIAT TRADITIONAL
GOVERNMENT
P.O. Box 1130, Barrow Alaska 99723 • PHONE: 907-852-4411 • FAX 907-852-8844
1
Dear Applicant,
Please choose/check which program you are applying for:
New Construction (NC) Renovation (REN)
Emergency Repair (ERP)
Homeless Prevention (Shelter/Hotel)
Homeless Prevention (Rent Assistance)
Foreclosure Assistance
Inspection
Real Property Acquisitions
To assist us in keeping accurate records, please make sure to do the following:
1.
Include copies of income verification/1040 tax forms for all members of the household.
2.
Include copies of Criminal Background Check for all adult members of household.
3.
Include copies of deed to any land owned (if any).
4.
Make sure to update your application.
It is the responsibility of the applicant to update his/her application every 12 months. Applicants who
fail to update their application risk being placed in the "inactive file". Updates are also necessary
when jobs, family members, addresses, or phone numbers change. Even if everything stays the same,
updates should be done on an annual basis.
5.
Complete all questions to the best of your knowledge.
Incomplete information delays processing. Birthdays and social security numbers are needed for all
members of the household. If a section does not apply to your household, please write N/A.
6.
Other helpful information that should be included is:
If there is a disabled family member, include:
Proof and the nature of the disability (from hospital or state agency).
Annual disability and the cost for an assistance to allow family member to work.
*** Also include any rent, utilities, or child care expenses.
QUYANAQPAK!! If you have any questions, please call Mary Lou Leavitt, Scott Bailie, or Rebecca
Brower at (907) 852-4411. We will be happy to assist you in completing the application for Housing
Assistance.
NATIVE VILLAGE OF BARROW
IÑUPIAT TRADITIONAL
GOVERNMENT
P.O. Box 1130, Barrow Alaska 99723 • PHONE: 907-852-4411 • FAX 907-852-8844
2
We have (8) types of Assistance Programs:
• New Construction CNC) - ff you do not own a home and would like to apply for a new
home.
• Renovation (REHAB) - If you own the home and live in the home and are requesting
• Emergency Repair (ERP) -If you own the home and live in the home and have an
emergency request.
• Homeless Prevention Activity Program (Rent Assistance) -If you area a renter and
receive a termination letter due to back rent due. The applicant(s) would need to turn in a
copy of the termination letter and original contract that was signed with their landlord.
• Homeless Assistance (Shelter/Hotel) - If you are homeless and need a place until your
transition.
• Foreclosure Assistance -If you own the home and receive a foreclosure notice for non-
payment.
• Inspection - We can assist in obtaining an inspection for your home.
• Real Property Acquisition – If you're a land owner and are selling your property.
1.
Everyone who applies is required to turn in a Criminal Background Check from the NSB
Police Department -This process is done on their own and at the cost of the applicant. You will need
to go to the police department dispatch and show your ID/Driver's License and also pay the required
$20.00 foe. You will need to provide a money order paid to the state of Alaska for each background
check, make sure that the "original" is turned in with your application and we will give you the original
back after making a copy. (This is required by HU D)
2.
Please make sure to also bring your tribal card -you may either bring your Native Village
Tribal Card (or tribe you belong to), if you do not have an NVB card you may also use a BIA card. If
you do not have either of the two we will accept ASRC cards. (Please make sure you include these
cards for each person listed on the application).
3.
We will need a copy of your land deed to any land owned (if applicable).
4.
Please provide copies of your current taxes documents for yourself and all members of
household over the age of 18.
BIA Form 6407 OMB Control No. 1076-0184
ISSUED 01/01/2019 EXPIRATION DATE: 02/28/2022
Date of this application: ______________________
3
UNITED STATES DEPARTM ENT OF THE INTERIOR
BUREAU OF INDIAN AFFAIRS
HOUSING ASSISTANCE APPLICATION
• All questions in this application must be answered. The requested information is self-explanatory.
• This application is subject to the Privacy Act of 1974, Pub. L. 93-579
A. APLICANT INFORMATIONS _________________________________________________________
1. Name: ________________________ _____________________ _________________________
Last First First MI Maiden Name (if any)
2. Current Address: _____________________________ __________________________________
Street Address P.O. Box # (if any)
________________________________ ________________________ _________________________________
City State Zip Code
3. Telephone Number: ( ) _______________ 4. Date of Birth: ___________________________
5. Tribe: ___________________________________________ Roll Number: __________________
Reservation/Rancheria: ______________________________________________________________
6. Marital Status: MarriedSingled Widowed Other
If you checked "Other", please explain. __________________________________________________
7. Are you Homeless?
No
Yes 8. Are you or spouse a Veteran?
No
Yes
Information about Spouse: _______________________________________________________________
9. Name: ________________________ _____________________ _________________________
Last First First MI Maiden Name (if any)
10. Date of Birth: ________________
11. Tribe: ___________________________________________ Roll Number: __________________
B. FAMILY INFORMATION ___________________________________________________________
List all other persons living in household on a permanent basis. Start with the oldest and provide Name, Date
of Birth, Relationship to Applicant, and Tribe/Roll Number.
Name
Date of Birth
Relationship to Applicant
Tribe/Roll Number
If you need more space, use a blank sheet of paper.
BIA Form 6407 OMB Control No. 1076-0184
ISSUED 01/01/2019 EXPIRATION DATE: 02/28/2022
Date of this application: ______________________
4
12. Earned Income: Start with applicant, then list all permanent family members, including all who are
listed under Parts A and B and have earned income. Provide signed copy of SF-1040 (income tax return),
W-2 forms, wage stubs, etc. for verification.
Name
Source of Income
Total annual earned income: $ _________________________
13. Unearned Income: Start with applicant, then list all permanent family members, including all who are
listed under Parts A and B and have unearned income such as social security, retirement, disability and
unemployment benefits, child support and alimony, royalties, per capita payments, interest, etc. Provide
check stubs, statements, individual Indian Money (IIM) ledgers, etc. for verification.
Name
Annual Earned Income
Source of Income
Total annual earned income: $ _________________________
14. TOTAL COMBINED ANNUAL HOUSEHOLD INCOME (earned + unearned) $ ______________
D. HOUSING INFORMATION __________________________________________________________
15.
Location of the house to be repaired, renovated or constructed. (Give address and detailed directions
to this house). **DRAW MAP ON BACK OF THIS PAGE**
16.
Provide a brief description of the problems you are experiencing with your house or the type of
housing assistance for which you are applying.
17.
If repair assistance is needed do you own _______ or rent ________ this house?
If renting, is the owner Indian?
No
Yes
If yes, provide name of owner(s):
18.
Are you living in Overcrowded Conditions?
No
Yes
19.
Is the condition of the home in a dilapidated state?
No
Yes
BIA Form 6407 OMB Control No. 1076-0184
ISSUED 01/01/2019 EXPIRATION DATE: 02/28/2022
Date of this application: ______________________
5
HOUSING INFORMATION, continued.
20.
Is electricity available?
No
Yes If yes, provide name of electric company: _________________
21.
Type of Sewer system:
City Sewer
Septic Tank
Chemical
Toilet Outhouse
Water Source:
City Water
Private Well Community
Water Tank
Other (Please describe):
22.
No. of Bedrooms __________.
23.
House Size: ___________ (Square Feet)
[LENGTH ft/in] [WIDTH ft/in]
24.
Bathroom facilities in existing house:
Facility
Yes
No
Flush toilet
Bathtub
Sink/lavatory
E. LAND INFORMATION _______________________________________________________________
25.
Do you own the land on which you wish to renovate or build this home?
Yes
No
If no, can you provide proof that you can obtain land?
Yes
No
Provide name of the owner(s): ____________________________________________________
26.
What is the current
status of the land?
Fee
Tribal Fee
Native/Restricted
Individual trust land
Tribal trust land
Public Domain
Individually restricted
Tribally restricted
Other:
27.
If you do not own the land, do you have:
Leasehold interest?
Use permit?
Indefinite assignment or joint ownership? If so, please explain: _____________________________
F. GENERAL INFORMATION __________________________________________________________
Yes
No
28.
Have you or anyone in your household ever received Housing Improvement Program
assistance?
If yes, give amount received $ __________; the year it was received: 19____ ; and the
location of the house:
29.
Do you own any other house not occupied by your family?
If yes, state where the house is located: and who occupies it:
30.
Do you live in a house built with Housing and Urban Development (HUD) funds?
31.
Is the HUD project still under operation of an Indian Housing Authority?
32.
Are you seeking Down Payment Assistance?
If yes, have you applied with USDA Rural Development or other lending institution?
Please provide a copy of the credit letter.
33.
If you are requesting assistance for a new housing unit, have you applied for
assistance from:
• Indian Housing Authority? If yes, provide date of application:
• Tribal Credit Program? If yes, provide date of application:
• Other? From who: ____________ If yes, provide date of application:
34.
Does anyone in your family, who is a permanent resident listed under Parts A and B of this
application, have a severe health problem, handicap or permanent disability?
disability?
If yes, provide name of family member ____________ and brief description of condition. (Your servicing
housing office will advise you if you must provide a statement of condition from one source, which may
include a physician's certification, Social Security or Veterans Affairs determination, or similar determination).
BIA Form 6407 OMB Control No. 1076-0184
ISSUED 01/01/2019 EXPIRATION DATE: 02/28/2022
Date of this application: ______________________
6
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
your application.
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.
click to sign
signature
click to edit
click to sign
signature
click to edit
NATIVE VILLAGE OF BARROW
IÑUPIAT TRADITIONAL
GOVERNMENT
P.O. Box 1130, Barrow Alaska 99723 • PHONE: 907-852-4411 • FAX 907-852-8844
7
APPLICANT OR PARTICIPANT STATEMENT FOR 1040 TAXES
I hereby certify that the information given to the NVB-Housing Department pertaining to
the (year) _________
I DO NOT file taxes, nor does anyone in
my household file for taxes. (By signing as household member(s) you are agreeing to the
fact that you do not file for taxes).
**Reason(s) for not filling (reason MUST be in detail, per HUD Policies).
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
I understand that false statements or information are punishable under federal law. I
also understand that false statements or information are grounds for denial of
housing assistance.
________________________________________________________________________
Signature of Head of Household Date
________________________________________________________________________
Signature of Spouse Date
________________________________________________________________________
Signature of Household Member Date
________________________________________________________________________
Signature of Household Member Date
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
NATIVE VILLAGE OF BARROW
IÑUPIAT TRADITIONAL
GOVERNMENT
P.O. Box 1130, Barrow Alaska 99723 • PHONE: 907-852-4411 • FAX 907-852-8844
8
RELEASE OF INFORMATION
I, ____________________________, Date of Birth: ________________ SSN: ______________________
(Applicant)
I, ____________________________, Date of Birth: ________________ SSN: ______________________
(Co-Applicant)
Authorize:
State of Alaska
Public Assistance 675 7th Avenue
Fairbanks, Alaska 99701
Tel: (800) 478-2850
Fax: (800) 451-2923
Arctic Slope Regional Corp Stock
Department
Box 129
Barrow, Alaska 99723
Tel: (907) 852-8633
Fax: (907) 852-9457
Toll Free: 800-770-2772
Social Security Administration
101121h Avenue
Box 9
Fairbanks, Alaska 99701
Tel: (907) 478-0391
Fax: (907) 456-0333
State of Alaska
Permanent Fund Dividend
Box 11462
Juneau, Alaska 99811-0462
Tel: (907) 465-2326
Fax: (907) 465-3470
Ukpeagvik Inupiat Corporation
Stock Department
Box 890
Barrow, Alaska 99723
Tel: (907) 852-4460
Fax: (907) 852-4459
To release information regarding any financial assistance, dividend payments or other kinds of income or public
assistance to any of the following:
Scott Bailie
Housing Director
Native Village of Barrow
Box 1130
Barrow, Alaska 99723
Tel: (907) 852-8918
Fax: (907) 852-4005
Rebecca Brower
Compliance Officer
Native Village of Barrow
Box 1130
Barrow, Alaska 99723
Tel: (907) 852-8905
Fax: (907) 852-4005
Mary Lou Leavitt
Occupancy Specialist
Native Village of Barrow
Box 1130
Barrow, Alaska 99723
Tel: (907) 852-8930
Fax: (907) 852-4005
For the purpose of evaluating my application for services through the Native Village of Barrow Housing
Department. I understand that the information released will be treated in a confidential manner and will not
be released to other persons or agencies without my specific authorization. This authorization expires 90
days from the date of my signature.
_______________________________________ _________________________
Applicant Date
_______________________________________ _________________________
Co-Applicant Date
NATIVE VILLAGE OF BARROW
IÑUPIAT TRADITIONAL
GOVERNMENT
P.O. Box 1130, Barrow Alaska 99723 • PHONE: 907-852-4411 • FAX 907-852-8844
9
RELEASE OF INFORMATION
I, ____________________________, Date of Birth: ________________ SSN: ______________________
(Applicant)
I, ____________________________, Date of Birth: ________________ SSN: ______________________
(Co-Applicant)
Authorize:
Name:
Address:
Phone:
Fax:
Name:
Address:
Phone:
Fax:
Name:
Address:
Phone:
Fax:
Name:
Address:
Phone:
Fax:
Name:
Address:
Phone:
Fax:
Name:
Address:
Phone:
Fax:
To release information regarding any financial assistance, dividend payments or other kinds of income or public assistance to
any of the following:
Scott Bailie
Housing Director
Native Village of Barrow
Box 1130
Barrow, Alaska 99723
Tel: (907) 852-8918
Fax: (907) 852-4005
Rebecca Brower
Compliance Officer
Native Village of Barrow
Box 1130
Barrow, Alaska 99723
Tel: (907) 852-8905
Fax: (907) 852-4005
Mary Lou Leavitt
Occupancy Specialist
Native Village of Barrow
Box 1130
Barrow, Alaska 99723
Tel: (907) 852-8930
Fax: (907) 852-4005
For the purpose of evaluating my application for services through the Native Village of Barrow
Housing Department. I understand that the information released will be treated in a confidential manner
and will not be released to other persons or agencies without my specific authorization. This
authorization expires 90 days from the date of my signature.
_______________________________________ _________________________
Applicant Date
_______________________________________ _________________________
Co-Applicant Date
APPLICANT OR PARTICIPANT STATEMENT:
NATIVE VILLAGE OF BARROW
IÑUPIAT TRADITIONAL
GOVERNMENT
P.O. Box 1130, Barrow Alaska 99723 • PHONE: 907-852-4411 • FAX 907-852-8844
10
I hereby certify that the information given to the Native Village of Barrow Housing Department
on credit, references, and tenant history is accurate and complete to the best of my knowledge
and belief. I understand that false statements or information are punishable under federal law. I
also understand that false statements or information are grounds for termination or denial of
housing assistance.
I understand that after verification by this Housing Authority, the information will be submitted
to the department of Housing Urban Development on HUD form 50058 (Tenant Data Summary),
a computer generated facsimile of the form or on magnetic tape.
**I acknowledge that I have received and signed a Federal Privacy Act Statement.**
(Household member(s) 18 and over)
________________________________________________________________________
Signature of Head of Household Date
________________________________________________________________________
Signature of Spouse Date
________________________________________________________________________
Signature of Household Member Date
________________________________________________________________________
Signature of Household Member Date
________________________________________________________________________
Signature of Household Member Date
________________________________________________________________________
Signature of Household Member Date
IF YOU BELIEVE THAT YOU HAVE BEEN DISCRIMINATED AGAINST, OR HAVE
QUESTIONS ABOUT THE LAWS OF DISCRIMINATION, CONTACT THE ALASKA
STATE COMMISSION FOR HUMAN RIGHTS AT, 1-800-478- 4692, OR YOU MAY
CONTACT THE FEDERAL OFFICE OF FAIR HOUSING AND EQUAL OPPORTUNITY AT
206-220-5 170.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

NATIVE VILLAGE OF BARROW IUPIAT TRADITIONAL GOVERNMENT (Native Village of Barrow)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 27 January 2021

Message

View Audit Log
Print With Audit Log
Duplicate Document