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Enclosed is the housing application that you have (The Chickasaw Nation)

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Dear Applicant:
Enclosed is the housing application that you have requested. Please read the attached checklist
carefully as all requested information must be provided before we process your application(s); incomplete
applications will be returned.
Listed below are the documents required for processing your application:
Chickasaw citizenship card and/or Certificate of Degree of Indian Blood (CDIB) card for
head of household or spouse.
Social security cards for all household occupants.
Driver’s License/photo ID for anyone 18 or older.
Birth Certificates/proof of custody for all children.
Employment verifications for all household members who are age 18 years or older.
Retirement, TANF, unemployment benefits, workers compensation, social security benefits,
SSI, DHS, college grants/scholarships, or child support (money received) of all household
occupants. If you do not have an income, you must complete a Zero Income Questionnaire.
If you own land, a home/mobile home, etc., an appraisal of the property will be required.
This will need to be done by a real estate associate, broker, etc. and must be on their
letterhead showing the current market value.
All persons 18 years and older-
1)
Sign and date the Release of Information
2)
Privacy Act and
3)
Background check forms
The Conflict of Interest Disclosure must be completed and signed by applicant.
We look forward to providing you with this service. If we can be of assistance to you in completing
the application, you may contact our office at (580) 421-8800.
Sincerely,
Admissions Specialist
Housing Management Services
Enclosures
Form no. 04852HRCL CS-HOU Rev. 6/2018
Page 2 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
THE CHICKASAW NATION HOUSING DIVISION
HOUSING PROGRAMS
“98” RENTAL ASSISTANCE PROGRAM (RAP)
This program allows for houses, apartments and mobile homes to be leased from landlords who
own rental property within the Chickasaw Nation service area (see attached map). Approved
applicants will be invited to an information briefing to receive their housing vouchers.
Program requirements:
Native American with a Certificate of Degree of Indian Blood
Low income
“37” RENTAL ASSISTANCE PROGRAM
Provides rental assistance to tenants in apartments that are owned by the Chickasaw Nation
Housing Authority. Apartment complexes are located at:
ADA DISTRICT ARDMORE DISTRICT DUNCAN DISTRICT
Allen Ardmore Duncan
Byng Healdton Marlow
Davis Marietta Rush Springs
Latta Tishomingo
Marie Bailey Sr. Site
Stonewall
Sulphur
Program requirements:
Native American preference
Low income
Applications must be updated every six months.
Priority for rental assistance programs: Priority 1 All Chickasaw citizens
Priority 2 All other Native Americans
Additional preference is given to families that are elderly, disabled or a Veterans.
HOMEOWNERS PROGRAM
This program offers a home ownership opportunity of new homes at an affordable cost. Houses
are built by the Chickasaw Nation Housing Division within the Chickasaw Nation service area
(see attached map).
Program requirements:
Native American with a Certificate of Degree of Indian Blood
Minimum yearly income of $21,300.00
Maximum annual income is determined by established Federal guidelines
Priority for Homeowners Program: Priority 1 All Chickasaw citizens
Priority 2 All other Native Americans
Additional preference is given to families with children, couples with no children and Veterans.
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Form no. 04852HRCL CS-HOU Rev. 6/2018
Page 3 of 13
Page 4 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
Same as Mailing
Department of Community Services / Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
PLEASE CHECK ALL PROGRAMS THAT MAY APPLY:
Homeowners Program “37” Rental Assistance Program “98” Rental Assistance Program
Applicant name:
First Middle Last Suffix
Mailing address:
Street City State ZIP
Physical address:
Street City State ZIP
Phone: Work: ( ) - Cell: ( ) - Email:
Desired location: Town: County:
***(See attached for “37” Rental Assistance Program locations)*** Selected location:
Family composition - complete the information below for all family members who are living in your home:
Name of family
member
Date of
birth
Sex
Relationship to
head of household
SSN
Age
Employer
Head of household
Is any member of your household handicapped or disabled? Yes No
Is any member of your household a Veteran? Yes No (If yes, DD214 Form required)
Additional Income Information
Does any member of your household attend college or vo-tech? Yes No Receive grants? Yes No
List type of grant and amount:
Does any member of your household receive cash contributions from individuals not living with you? Yes
No $ / per week/month.
Does any member of your household receive child support? Yes No If yes, list amount: $
Family Assets Information
Does any member of your household have a checking/savings account? Yes No
Bank name: Address: Account #:
Bank account balance: $
Does any member of your household receive income from interest or dividends from certificates of deposit,
stocks or bonds? Yes No
Bill Anoatubby
Governor
Page 5 of 13 Form no. 04852HRCL CS-HOU Rev. 6/2018
If yes, list name and address of institution from which you purchased such:
Monetary value: $
Have you disposed of assets within the last two year (e.g.: land, house, money, automobile, etc.)? Yes No
If yes, please provide proof and value of said asset: $
Please list all assets that you currently hold (e.g.: land, house, money, automobile, etc.):
Does any member of your household own interest and receive revenue checks from oil or gas wells? Yes
No If yes, give monthly amount? $ Name and address of company:
(See reverse side)
Current Housing Information
Present living conditions: Are you renting, buying a home/mobile home or living with relatives?
If you presently own a home, explain conditions:
.
If renting, amount of rent: $ Number of bedrooms: Name of landlord:
Address: Phone number: ( )
Previous address: Name of landlord:
Amount of rent: $ Address:
Phone number: ( )
Previous Housing Information
Have you ever received Rental Assistance? Yes No If yes, what agency?
Have you ever received Low Rent or Homeownership Housing? Yes No
If yes, what agency?
Do you currently owe the Chickasaw Nation Housing Division any outstanding balance? Yes No
If approved for the housing program, can you furnish your own building site? Yes No
Do you own the title to this land? Yes No How long have you been in possession of this land? ______
IF “YES” IS CHECKED ON THE FOLLOWING FELONY QUESTION, PLEASE EXPLAIN THE CHARGE, DATE OF THE CHARGE
AND SENTENCING ON THE LINES BELOW. YOU WILL ALSO NEED TO PROVIDE LEGAL DOCUMENTATION. IF “YES” IS
CHECKED FOR DRUG COURT PLEASE PROVIDE DOCUMENTATION ON WHAT PHASE YOU ARE IN.
Have you ever been arrested or convicted of a felony? Yes No
Are you currently participating in a drug court program? Yes No
Are you a registered sex offender? Yes No
List name, address and phone number of two relatives or friends who generally know how to contact you.
Name of contact person
Address
Phone number
Relationship
Page 6 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
Ethnic group (statistical purpose only)
1. White, not of Hispanic origin 2. Black, not of Hispanic origin 3. American Indian or Alaskan Native
4. Hispanic 5. Other Tribal affiliation:
I understand that the above information is being collected to determine my eligibility for housing services.
Information given will be verified and may be released to appropriate federal, state or local agencies. I certify
that the statements in this application are true and complete to the best of my knowledge and belief. I
understand that incorrect information or false statements are punishable under federal law.
Signature of head of household: Date:
Signature of spouse: Date:
INTERNAL USE ONLY
******************************************************************************************************************************************
Preference category:
#1 –Chickasaw citizen #2 – Other Native American #3 – Non-Native (“37” Rental Assistance Only)
Priority: ________ Ranking points: _______ Bedroom size: _______
CERTIFICATION: On the basis of the determination set forth above, the applicant family named herein
has been found to be: Eligible for admission Ineligible
Reason for ineligibility:
Signed:
Title:
Date:
Background check completed: Date:
Sex offender check completed: Date:
Division use only
Date: __________________
Time: __________________
Initial: _________________
OVERCROWDED ___YES ___NO
Form no. 04852HRCL CS-HOU Rev. 6/2018
Same as Mailing
Department of Community Services / Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Request for Release of Information
Family/individual: Date:
First Middle Last Suffix
Mailing address:
Street City State ZIP
Physical address:
Street City State ZIP
Phone: Work: ( ) - Cell: ( ) - Email:
You are requested to provide the Chickasaw Nation Housing Division any information from your
records which is needed by the housing division in determining eligibility for the above named
participant/tenant and his/her family.
Your cooperation and prompt return of the information will be appreciated and this information will be
held in confidence and used only by the housing division as legally permissible.
I give my permission for you to release this requested information to the Chickasaw Nation Housing
Division.
Signature of head of household Social Security number
Signature of spouse Social Security number
Signature of other adult member Social Security number
Signature of other adult member Social Security number
Bill Anoatubby
Governor
Page 7 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
Department of Community Services / Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Privacy Act Notice
The Chickasaw Nation Housing Division is authorized to collect information by the Native
American Housing Assistance and Self Determination Act of 1996 (NAHASDA). You must provide
all of the information requested by the housing division, including all Social Security numbers you
and all other household members age six years and older have and use.
Your income and other information are being collected by the division of housing to determine
your eligibility, the appropriate bedroom size and the amount your family will pay toward rent. This
information may be released to appropriate federal, state and local agencies when relevant and to
civil, criminal or regulatory investigators and prosecutors pursuant to federal law.
The information will not be otherwise disclosed or released except as permitted or required by
law. Failure to provide any of the requested information may result in a delay or rejection of your
eligibility approval.
Head of household Date
Spouse Date
Other adult member Date
Other adult member Date
Bill Anoatubby
Governor
Page 8 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
Department of Community Services / Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Background Check Verification
Please complete the top portion of this form and return with your application. You may
take this form to your local law enforcement agency for completion or the Housing
Division will ensure that the background check is completed.
The individual listed below has applied for housing at the Chickasaw Nation Housing Division
(OK062029Q). Please furnish information on any possible felony arrests and/or convictions for
the name listed below.
Name:
First Middle Last Suffix
Social Security number:
Driver’s License number:
Date of birth:
Housing division representative Date
I HEREBY AUTHORIZE THE RELEASE OF THE ABOVE REQUESTED INFORMATION.
Applicant/tenant signature Date
Our records indicate the individual above possibly does not have a record of a felony arrest
or conviction.
Our records indicate the following possible felony arrests or convictions.
Authorized official – title Date Phone number
County stamp
Bill Anoatubby
Governor
Page 9 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
Department of Community Services / Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Conflict of Interest Disclosure
The Chickasaw Nation Housing Division takes seriously any actual or potential conflicts of
interest. As we wish to avoid even the appearance of a conflict, we ask all applicants to
disclose any immediate family members, or other significant persons, which could potentially
cause a conflict of interest. For this purpose, immediate family member includes, but is not
limited to, spouse, children, parents and siblings.
Please list any relationship here (please print):
Attestation: The undersigned individual(s) hereby attest(s) that he/she is a participant in one
or more of the housing division programs and that he/she is independent of and has no conflict
of interest with any persons not listed above.
Signature of head of household Date
Signature of spouse Date
FOR DIVISION USE ONLY:
CURRENT HOUSING SITUATION PRIOR TO ASSISTANCE
OVERCROWDED SUBSTANDARD
ELDERLY/SUBSTANDARD HOMELESS
DISABLED STUDENTS ASSISTED WITH
RENTAL TO OWNER HIGHER EDUCATION
Bill Anoatubby
Governor
Page 10 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
Department of Community Services / Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Banking Verification
Applicant/tenant: Date:
Address: Social Security number:
Social Security number:
Account number:
I hereby grant the Chickasaw Nation Housing Division permission to make inquiries regarding my
income and assets. I understand that this information will be kept confidential.
Applicant/tenant signature

**TO BE COMPLETED BY YOUR BANKING INSTITUTION**
Current checking account balance:
Interest rate paid:
Interest received in the past 12 months:
Current savings account balance:
Interest rate paid:
Interest received in the past 12 months:
Amount of savings certificates:
Interest rate paid:
Interest received in the past 12 months:

Name of institution:
Address: Phone: ( )
By: Title: Date:
Housing representative
Bill Anoatubby
Governor
Page 11 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
Department of Community Services / Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
EMPLOYMENT INCOME VERIFICATION
Employee name: Date:
Employee address: Soc. Sec. no.:
The Chickasaw Nation Housing Division is required to verify the income of all applicants/tenants/participants of
the programs. The person named above states that he/she is now employed by your firm. Your cooperation in
supplying the information requested below will be appreciated and of benefit to your employee. Such
information will be held in confidence and used only by the housing division as legally necessary.
Date Housing division representative
I hereby authorize the release of this information to the Chickasaw Nation Housing Division.
Date Employee signature
INFORMATION BELOW IS TO BE COMPLETED BY EMPLOYER ONLY!
********************************************************************************************************************************
1. Date of employment:
2. Occupation:
3. Employment is: Permanent: Temporary: Part-time: Seasonal:
If seasonal or temporary, please explain:
4. Current average number of hours worked per week: Straight time: Overtime:
5. Current base pay rate: $ per: Date effective:
6. Expected change in rate of pay (date):
New base pay rate: $ per:
7. If overtime rate is paid, at what rate is it paid: $ __________________________
8. Amount of bonus, incentive pay, commission and/or tips: $ per:
9. If seasonal or sporadic employment, give lay-off periods:
10. Does this employee receive vacation with pay? Sick leave with pay?
11. Amount deducted for medical/hospital insurance: $ per:
Weekly, bi-weekly, monthly
12. Amount deducted for child support: $ per:
Weekly, bi-weekly, monthly
13. Anticipated total earnings for next 12 months: $
The above information is true and correct to the best of my knowledge. I understand that any false
statements of information are punishable under federal law.
Date: By:
Firm name: Title:
Address: Phone: ( )
Bill Anoatubby
Governor
Page 12 of 13
Form no. 04852HRCL CS-HOU Rev. 6/2018
Department of Community Services / Housing Division
111 Rosedale Road / P.O. Box 788 / Ada, OK 74820-0788 / (580) 421-8800 / Fax (580) 421-8885
Zero Income Verification
This form is to be completed by all adults living in the household who do not have income.
Answer the questions below either no or yes.
I, , do certify that I do not have income from any source:
Include the following:
No Yes - Income from performing odd jobs (yard maintenance, house cleaning, baby-sitting, etc.)
No Yes – Income received from relatives or friends to aid in maintaining my household.
No Yes – Income received from child support or alimony.
No Yes – Income from unemployment, Social Security, welfare (DHS), Veterans Administration
or Workers Compensation.
$ - Income from grants and scholarships.
$ - Income received from employment or retirement.
**PLEASE STATE HOW YOU PAY FOR EVERYDAY EXPENSES (RENT, UTILITIES, FOOD, ETC.)**
Should my income status change, I will notify the Chickasaw Nation Housing Division immediately so that
proper verification can be obtained.
I acknowledge that any misrepresentation of income, assets or family composition used from my application
to determine eligibility may result in termination of participation in the program, or I may be required to pay
the difference between the total tenant’s payment paid and the amount which should have been paid.
Signature of applicant/tenant Date
Housing division representative Date
Bill Anoatubby
Governor
Page 13 of 13
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Completed 31 January 2021

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