Form 6407 Housing Assistance Application

BIA Form 6407 OMB Control No. 1076-0084

ISSUED 0X/XX EXPIRATION DATE: XX/XX/XXXX

UNITED STATES DEPARTMENT 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. APPLICANT INFORMATION_______________________________________________________

1. Name:__________________ _________________ __ ___________________

Last 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. Social Security Number: ______________________

6. Tribe: _____________________________________________ Roll Number: ____________

Reservation/Rancheria: _________________________________________________________

7. Marital Status: ____Married ____Singled ____Widowed ____Other

If you checked “Other”, please explain. ______________________________________________________________

_____________________________________________________________________________________________

Information About Spouse:

8. Name:__________________ _________________ __ _______________________

Last First MI Maiden Name (if any)

9. Date of Birth: ________________ 10. Social Security Number: _____________________

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, Social Security Number, Relationship to Applicant, and Tribe/Roll Number .

Name	Date of Birth	Social Security #	Relationship to Applicant	Tribe/Roll Number

If you need more space, use a blank sheet of paper.

BIA Form 6407 OMB Control No. 1076-0084

ISSUED 0X/XX EXPIRATION DATE: XX/XX/XXXX

C. INCOME INFORMATION__________________________________________________________

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	Annual Earned Income	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 Unearned Income	Source of Income

Total annual unearned 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.	To your knowledge, has HIP assistance ever been provided for this house or have you ever received HIP assistance?
	___ No.
	___ Yes. If yes, indicate amount: $___________, to whom: __________________________, and when: ___________.
18.	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):

BIA Form 6407 OMB Control No. 1076-0084

ISSUED 0X/XX EXPIRATION DATE: XX/XX/XXXX

HOUSING INFORMATION, continued.

19.	Is electricity available? ____No ____Yes If yes, provide name of electric company: _______________.

20.

Type of Sewer system:

___ City Sewer

___ Septic Tank

___ Chemical Toilet

___ Outhouse

21.	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, provide the 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.	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:____________
33.	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?

If yes, provide name of family member __________________ and brief description of condition. (Your servicing housing office will advise you if you must provide statements of condition from two sources, which may include a physician’s certification, Social Security or Veterans Affairs determination, or similar determination).

BIA Form 6407 OMB Control No. 1076-0084

ISSUED 0X/XX EXPIRATION DATE: XX/XX/XXXX

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 (if appropriate) _________________________ 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-3642, Washington, DC 20240.

Created: October 3, 2001, 10:41:11 AM modified: September 19, 2007

Date of this application:________

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