DHHL Form Request for Certification of Eligibility

REQUEST FOR CERTIFICATION OF ELIGIBILITY

INSTRUCTIONS
LENDER OR LOCAL PROCESSING AGENCY: Complete items 1 through 7. Have applicant complete item 8. Forward

directly to the Department of Hawaiian Home Lands (DHHL).
DHHL: Please complete Parts II and III and return DIRECTLY to Lender or Local Processing Agency named in Item 2.

PART I – REQUEST
1. TO: Department of Hawaiian Home Lands

2. FROM: (Name of Lender or Local Processing Agency)

ATTN: Loan Services Branch
P.O. Box 1879
Honolulu, HI 96805
I CERTIFY THAT THIS CERTIFICATION HAS BEEN SENT DIRECTLY TO DHHL AND HAS NOT PASSED
THROUGH THE HANDS OF THE APPLICANT OR ANY OTHER PARTY.
3. Signature of Lender or Official of
4. Title
5. Date

Local Processing Agency

INFORMATION TO BE CERTIFIED:
Applicant is a native Hawaiian possessing a homestead lease on Hawaiian home lands as referenced in Section 184A of
the Housing and Community Development Act of 1992 (12 U.S.C. 1715z-13b). Applicant holds the following homestead
lease in good standing (not cancelled or in default):
Lease No.
to TMK:
Effective Date:
6.

TO DHHL: I have applied for a Native Hawaiian Housing Loan Guarantee and stated that I have an effective lease on
Hawaiian home lands. You are authorized to verify this information and to supply this lender or local processing agency
identified above with the information requested in items 9 through 12. DHHL is held harmless by me for furnishing true
and correct information.
7. NAME AND ADDRESS OF APPLICANT
8. SIGNATURE OF APPLICANT AND SSN:

__

______

PART II – TO BE COMPLETED BY DHHL
9. VERIFICATION OF NATIVE HAWAIIAN APPLICANT: The above named applicant has been verified as a native

Hawaiian possessing a homestead lease in good standing (not cancelled or in default) issued under Section 207(a) of the
Hawaiian Homes Commission Act of 1920, as amended and referenced in Section 184A of the Housing and Community
Development Act of 1992 (12 U.S.C. 1715z-13b).
__________________________________________________________________________________________________
10. LEASE INFORMATION:

LEASE NO.
COMMENCEMENT DATE OF LEASE:
LEASE RENT:
CURRENT?
REAL PROPERTY TAXES: CURRENT?

TMK:
YES
YES

NO
NO

_______(LESSEES ARE EXEMPT FROM REAL PROPERTY TAXES FOR SEVEN YEARS FROM COMMENCEMENT DATE OF LEASE.)__

11. DHHL LOANS OUTSTANDING
LOAN NO.

DATE OF LOAN

ORIGINAL AMT.

CURRENT BAL.

INSTALLMENTS

NO. OF LATE PMTS.
W/IN LAST 24 MOS.
30
60
90

12. ADDITIONAL INFORMATION WHICH MAY BE OF ASSISTANCE IN DETERMINATION OF CREDIT
WORTHINESS: (Please include information on loans paid in full.)

PART III – CERTIFICATION
________________________________________________________________________________________________________________________

13. Signature

14. Title

15. Date

RETURN DIRECTLY TO LENDER OR LOCAL PROCESSING AGENCY
DHHL Form