Housing Authority of the Nation 1500 Hensley Drive P.O. Box 1007 Tahlequah, OK 74465-1007

Phone 918-456-5482 Toll Free 800-837-2869

Housing Rehabilitation Program Application

The HACN Housing Rehabilitation Program is designed to provide rehabilitation services for privately owned homes for low-income Native American tribal members who reside within the . Preference will be given to Cherokee Nation Tribal citizens.

Eligibility Requirements include: • Household income must be at or below 50% of the National Median Income Guidelines. • Applicant must be the owner/occupant of record of the unit to be assisted. • The home must be the family’s primary residence. • The applicant must have and maintain adequate homeowner’s insurance coverage. • Criminal background checks will be conducted on all household members 18 years of age and older. • Other eligibility requirements will apply according to the HACN Rehabilitation Program Policy.

The following items will be required during the application process: 1. Verification of tribal membership 2. Copies of social security cards for all members of the household over 5 years of age. 3. Copies of government issued photo ID’s for all household members 18 years of age and older. 4. Income verification for all household members 18 years of age and older. 5. Copy of Warranty Deed and title, if applicable. 6. Verification of disability, if applicable.

Staff is available in the following offices to accept applications and provide assistance.

Adair County Mayes County

Alyene Hogner Heights Cherokee Heights 160 Alyene Drive 100 Cherokee Heights Stilwell, OK 74960 Pryor, OK 74361

Bushyhead Heights Willard Stone Heights 150 Goingsnake Rd 300 Willard Stone Circle Westville, OK 74965 PO Box 1240 Locust Grove, OK 74352 Cherokee County Muskogee County Housing Management 110 McSpadden Ct Houston Johnson Heights PO Box 1007 North 6th Ave Tahlequah, OK 74465 Warner, OK 74469

Leon Daniel Heights Nowata County 701 W. Fox St. Wauhillau Court Tahlequah, OK 74464 115 Wauhillau Court Nowata, OK 74048 Proctor Heights 900 Bassham County PO Box 627 Hulbert, OK 74441 Sallisaw HACN Office 2260 W. Cherokee Craig County PO Box 469 Sallisaw, OK 74955 Tom Buffington Heights 900 McNelis #31-B Rogers County Vinita, OK 74301 Claremore HACN Office Delaware County 23205 S. HWY 66 PO Box 1325 Jay HACN Office Claremore, OK 74018 109 13th Street PO Box 328 Will Rogers Sr Complex Jay, OK 74346 202 Stuart Roosa Claremore, OK 74017 Chopper Heights 434 Chopper Court Cherokee Village Grove, OK 74344 310 Chief Catoosa, OK 74015

Washington County

Keeler Heights 1003 S. Virginia Bartlesville, OK 74003

Housing Authority of the Cherokee Nation 1500 Hensley Drive P.O. Box 1007 Tahlequah, OK 74465-1007 Phone 918-456-5482 Toll Free 800-837-2869

Housing Rehabilitation Application

COMPLETE IN BLACK OR BLUE INK ONLY (NO PENCIL/NO WHITE-OUT)

______DATE: ______NAME FOR OFFICE USE ONLY: ______MAILING ADDRESS RECEIVED BY: ______DATE/TIME: CITY STATE ZIP CODE ______FORWARD TO: WORK PHONE HOME PHONE/CELL ______COUNTY TRIBAL COUNCIL DISTRICT EMERGENCY CONTACT NAME:______PHONE______Directions to Home: ______HOUSEHOLD COMPOSITION: FULL NAME(S) of all Native Household Members Relation to Sex Date of American Social Security Number Last, First, Middle Head M/F Birth Y/N List Tribe ***REQUIRED*** 1. Head 2. Spouse 3. 4. 5. 6. Are there family members temporarily absent? ____Yes ____No If so, whom: ______Where are they residing? ______When are they expected to return? ______TOTAL HOUSEHOLD INCOME: Gross Child Social Unemploy- Weekly Welfare Support Security ment All Other Household Member(s) Employer Wages TANF Received Benefits Benefits Income 1. 2. 3.

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Housing Status: (Check all that apply) ______62 or older ______Disabled Is the head of household or spouse currently receiving disability benefits from the Social Security Administration or the Veteran’s Administration? _____ Yes _____ No Do you currently own your home? _____Yes _____No If NO, do you _____Rent _____Make a Mortgage/Bank Payment If so how much? ______Are you the legal owner of the property? ____Yes ____ No If you do not own, please provide the name(s) of owner(s)______Type of Dwelling: _____ Frame Home _____Mobile Home Number of Bedrooms: ______Year Built: ______Do you have homeowner’s insurance? _____Yes _____No Insurance Company: ______Water District: ______Fair Cash Market Value: ______Land Status: _____Fee Simple _____Restricted _____Trust Have you or any other person named on the application as intending to reside in the unit, ever been convicted for using, dealing, manufacturing illegal drugs, or violent criminal activity? _____ Yes _____ No Do you or any other person named on the application use any Schedule I drug as classified by the Controlled Substances Act, including marijuana regardless of medical or recreational use under any state law? _____ Yes _____ No

TYPES OF HOUSING REHAB SERVICES AVAILABLE (CHECK THE TYPE OF ASSISTANCE NEEDED)

EMERGENCY - Emergency home repairs are intended to protect, repair, or restore components of a home when there is an apparent threat to the life, health or safety of the occupants. Emergency applications will only be accepted when completed with a HACN employee, preferably in office.

____HOUSING ACCESSIBILITY - Provides accessibility ramps, structural modifications, structural assistive devices, roof & electrical repairs or other items needed to allow individuals better mobility and use of their home.

____ HOUSING REHAB – Major repairs that include health and safety items, such as: water, septic/sewer, electrical, plumbing, roof, heat & air, energy conservation, cabinets, termite treatment, and/or floor covering to prevent a safety/tripping hazard, etc.

____WEATHERIZATION - Assistance to repair, restore or winterize a property in order to alleviate weather concerns. Program is for elderly and disabled families only.

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____DRIVEWAY REPAIR - Program provides improved access to driveways or sidewalks for health and safety purposes or for medical necessity. Program is for elderly and disabled families only.

____STORM SHELTER - Program will provide storm shelters to qualifying families. Program is for elderly and disabled families only.

____MATERIALS ONLY – Self-help program which allows participants to perform the necessary rehabilitation work on their own homes, or hire a contractor or qualified work force to complete the work for them at their own expense. Program is for elderly and disabled families only.

PREVIOUS PARTICIPATION

Have you or any member of the household ever received housing services from another Tribe/Tribal Housing Authority, Public Housing Authority, Cherokee Nation, or the Housing Authority of the Cherokee Nation?

_____YES _____NO

If you have had a home before please provide information as to when the home was given up and list the name of the agency who built it, state the reason why and which project (if known) and the name of person(s) to whom it was assigned (if known). Also, state the condition of the house and if there was a delinquent balance.

______

Have you or any member of the household ever received assistance from one or more of the following programs? a. Rehab to Home ___Yes ____No e. Mortgage Assistance ____Yes ____No b. Mutual Help (Indian home) ____Yes ____No f. Rural Rental Home ____Yes ____No c. Water and Sanitation ____Yes ____No g. HIP ____Yes ____No d. Self-Help Housing (SIP) ____Yes ____No h. New Const Home ____Yes ____No

If you are participating or have participated in any of the programs, please provide information as to when and what county/city you resided.

______

Do you or your spouse have any relative(s) presently working for, or holding office in the Cherokee Nation, or one of its entities? ____Yes ____No If yes, give the name(s) of relative(s), relation and entity and program.

______

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PLEASE READ BEFORE SIGNING APPLICATION PACKET. IN ORDER TO RECEIVE SERVICES, YOU MUST QUALIFY BY MEETING ALL ELIGIBILITY REQUIREMENTS AND PROGRAM FUNDING MUST BE AVAILABLE.

Warning: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful false statements of misrepresentation to any Department or Agency of the U.S. to any matter within its jurisdiction. APPLICANT CERTIFICATION I/We certify that the answers/information given on this application in reference to household composition, income, net family assets, allowances and deductions is accurate and complete to the best of my/our knowledge and belief. I/We understand that false statements or information are punishable under Federal Law. I/we also understand that false statements or information are grounds for termination of housing assistance and termination of tenancy. No record will be communicated to anyone or any agency unless requested in writing, either by the applicant or an officer or employee of the housing program or other Federal agency requiring it in the performance of their duties. This application will not be valid unless completely filled out. INCOMPLETE APPLICATIONS WILL BE RETURNED.

I hereby authorize the release of account information to and from other financial institutions I have supplied to the Housing Authority of the Cherokee Nation in connection with such evaluation. I understand the processing of this application will require providing my information to the Housing Authority of the Cherokee Nation.

Consent: I consent to allow the Housing Authority of the Cherokee Nation to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD/HACN’s assisted housing programs. I understand that income information under this consent form cannot be used to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations.

______Signature of Head of Household Date Social Security Number Signature of Spouse Date

PRIVACY ACT NOTICE: THIS INFORMATION IS TO BE USED BY THE AGENCY COLLECTING IT OR ITS ASSIGNEES IN DETERMINING WHETHER YOU QUALIFY AS A PROSPECTIVE PARTICIPANT OR BORROWER UNDER THE AGENCY’S PROGRAM(S). IT WILL NOT BE DISCLOSED OUTSIDE THIS AGENCY EXCEPT AS REQUIRED AND PERMITTED BY LAW. You do not have to provide this information, but if you do not, your application for approval as a prospective participant or borrower may be delayed or rejected, the information requested in this form is authorized by TITLE 38, USC, Chapter 37 (if VA by 12 USC, Section 1701 BT.SEQ;(if USDA/FmHA)

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