HHCDA Rental Application

Directions
Provided is the physical PDF document for your reference. Please feel free to print off as it may be easier to follow along. To print or download, hover your mouse over the PDF below and click. Next, select the appropriate icon on the top bar to either print or download. If you have any questions please do not hesitate to call the Ho-Chunk Housing Community Development office at 608-374-1245 or toll-free 800-236-2260 Ext 8809.

At the end of the form, you will have the option to preview your document before submission. We advise that you do so to double-check all of your information. Again the PDF is available here to print off and follow along if you so choose.

When ready to start press the "Next" button below.

APPLICATION PROCESS 2019
Applicants must complete the entire rental application and provide the following documents to establish eligibility:

► Submit a COMPLETE rental application, sign and date in appropriate areas. Incomplete rental application will NOT be processed.

► Submit Income Verification for all household members over the age of 18.

► Submit copy of Tribal Identification Card and/or Certificate Degree of Indian Blood (CDIB).

► Submit a copy of Social Security Cards for all family members in the household.

► Everyone over 18 years of age must sign and date all Federal and HUD
Forms.

Upon receipt complete application, all applicants will be screened for desirability.

Eligible applicants will be placed on a Waiting List. In order to remain on the Waiting List, it is the responsibility of the applicant to update their application on an annual basis. This is done by completing a Statement of Continued Interest form and returning it to the HHCDA office.

Please note:

To quality for Ho-Chunk Housing & Community Development Agency Rental Low Income Housing, you must not have a balance due to Ho-Chunk Housing & Community Development Agency and/or any existing balance must be paid in full.

For Confidentiality Reasons:
Ho-Chunk Housing & Community Development Agency will not provide any information to anyone other than the Applicant and/or Head of Household.

As required by Section 208 of NAHASDA:
Information regarding criminal conviction shall be requested by Tribally Designated Housing Entity (TDHE) for purposes of applicant screening, lease enforcement and eviction.

WHAT DO WE LOOK FOR IN BACK GROUND CHECKS?
• Period of five (5) years Background
✓ Unlimited period for Violent Crimes
✓ Murder
✓ Crimes against children
✓ Rape
✓ Assault with deadly weapons
✓ Sexual crimes

• Screen Applicant against Registered Sex Offenders and/or Sexual Predator database.

• Prior Eviction or Abandonment of any Rental Property

• Debt Obligations to HHCDA, Tribal Housing, and/or HUD Housing Authority. (MUST BE PAID IN FULL).

• Physical violence
✓ Domestic
✓ Resisting Arrest
✓ Battery
✓ Disorderly Conduct

• Criminal Activity
• Destruction of Property
• Damage to Property
• Theft
• Gang Activity
• Any Restraining Orders
• Fraud
• Habitual Criminal
• OWI
• Trespassing
• Drug or Alcohol Offenses

	Details
Vision
Hearing
Wheelchair
Physical

	Details
Cat
Dog
Other
Comments

	Details
Lived there from __ to __
Number of Bedrooms
Rent

III. Program Integrity
Applicant Name *

First Name Last Name
Have you ever been convicted of a felony? *

Yes No
Have you ever been convicted of a misdemeanor? *

Yes No
Have you ever been convicted of a violation a Tribal /City/State? *

Yes No

If you have used or are otherwise known by another name, list all such names below include Nickname(s) and Maiden Name *

	Details
1
2
3

I, Certify that the information given here are true and complete to the best of my knowledge. I authorize investigation of statements contained in this application. As may be necessary in a housing rental decision and fully understand that false or misleading information given on this application will be cause for denial or eviction. All information derived pursuant to the applicant background investigation is confidential and will not be released to anyone.
Signature *

Clear
Date *

Month Day Year
IV. Family Composition Information

	Name	SS#	Student	Relationship to Head	Date of Birth
Head
1
2
3
4
5
6
7

Please attach Social Security card for each household member

	Birth Place	Gender	1 x	2x	3x	4x	5x	Ethnicity Hispanic
Head
1
2
3
4
5
6
7

Race Codes:

1 = White
2 = Black/African American
3 = American Indian/Alaska Native
4 = Asian
5 = Native Hawaiian/Other Pacific Islan

	EC x	EN x	IN x	PV x	Alien Registration	Handicap
Head
1
2
3
4
5
6
7

Eligibility Codes:

EC = Eligible Citizen
EN = Eligible Noncitizen
IN = Ineligible Noncitizen
PV = Eligibility Pending

V. Employment/Income Information

Enter each type of income that any household member is receiving.
Family Member *

First Name Last Name
Source/Company *
Position *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Start Date *

Month Day Year
How Long *
Income Per *

Hour Week Month
Income Amount *
Income Type *
Family Member *

First Name Last Name
Source/Company *
Position *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Start Date *

Month Day Year
How Long *
Income Per *

Hour Week Month
Income Amount *
Income Type *
Family Member

First Name Last Name
Source/Company
Position
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Start Date

Month Day Year
How Long
Income Per

Hour Week Month
Income Amount
Income Type

VIII. References

Enter references that be contacted to determine housing eligibility Character References (MUST NOT BE NON RELATIVE OR IMMEDIATE FAMILY)
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
Emergency Contact Information
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *

Area Code Phone Number
Email *
example@example.com
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number

Area Code Phone Number
Email
example@example.com
IX. Certification of Information
WARNING! Title 189, Section 1001 of the United States Code, states that a person who knowingly and willingly makes false or fraudulent statements to any Department or Agency of the U.S. government is guilty of a felony.
I, understand that any misrepresentation of information or failure to disclose information in this application may disqualify me from
consideration for admission or participation, and may be grounds for eviction or termination of assistance.
I do hereby certify that the above information is true, accurate, and complete to the best of my knowledge.
Legal Name of Household: *
Head of Household Signature *

Clear
Date *

Month Day Year
Co-Applicant Signature *

Clear
Date *

Month Day Year
Other member over 18 Signature

Clear
Date

Month Day Year
Other member over 18 Signature

Clear
Date

Month Day Year
Other member over 18 Signature

Clear
Date

Month Day Year

U.S. Department of Housing and Urban (HUD) 2019 ANNUAL INCOME LIMITS

AUTHORIZATION FOR THE RELEASE OF INFORMATION
I/we, the undersigned, with this, authorize the HO-CHUNK HOUSING & COMMUNITY DEVELOPMENT AGENCY and their agents to obtain any information necessary to process the HUD housing application.

This information can be obtained from the following sources, and of the Programs of the HOCHUNK NATION, Federal, State, and/or Local governments and any of their agencies and representatives, Law Enforcement Agencies, Financial Institutions and current and prior Landlords.

This list is not all-inclusive and may include any additional agency, government, or private source, as deemed necessary by the HO-CHUNK HOUSING & COMMUNITY DEVELOPMENT AGENCY and/or their agents.

I/we, the undersigned, with this, release the HO-CHUNK HOUSING & COMMUNITY DEVELOPMENT AGENCY and/or their agents any requested infonnation from the following agencies: Federal, State, And Local governments Law Enforcement Agencies, Financial Institutions, and current or prior Landlords.

The information request can be return by fax, telephone, or in writing. This release is valid for fifteen (15) months from the date of the applicant's signature. This release is valid if photocopied and does not have to have an original signature.

I/we have read the terms and conditions of the AUTHORIZATION FOR THE RELEASE OF INFORMATION and with this, give consent for the release of any requested information.
Name of Applicant *

First Name Last Name
Applicant SSN *
Date of Birth *

Month Day Year
Applicant Signature *

Clear
Today's Date *

Month Day Year
Name of Co-Applicant

First Name Last Name
Co-Applicant SSN
Date of Birth

Month Day Year
Co-Applicant Signature

Clear
Today's Date

Month Day Year

FEDERAL PRIVACY ACT

The U.S. Department of Housing and Urban Development HUD will be collecting information you gave to the Ho-Chunk Housing and Community Development Agency at application or re-examination. HUD will collect the information on Form HUD 50058. The data it will collect includes name, sex, birth date, Social Security Number (SSN), income (by source), assets, certain deductible expenses, and rental payment.

The Privacy Act of 1974, as amended, requires us to tell about this. We also are required to tell you what HUD will do with the information.

HUD will use the information to manage and monitor HUD assisted housing programs. It also may verify whether the information is accurate and complete by doing a computer match.

HUD may give the information to Federal, State and local agencies when it will be used for civil, criminal or regulatory investigations and prosecutions. HUD also may make summaries of resident data available to the public. Other than these uses, HUD will not release the information outside HUD, except as permitted or required by law.

The Housing and Community Development Act of 1987, 42 U.S.C.3543 requires applicant and residents to give the Authority the SS(s) of household members at least six (6) years old. If you are an applicant and you gave been issued or use SS(s) and you do not give them to the Authority, the Authority is required to reject your application for housing assistance. If you are receiving housing assistance and you have been issued or us SSN(s) and you do not give them to the Authority, the Authority is required to evict your family or withdraw your housing assistance.

The U.S. Housing Act of 1937, as amended 42 U.S.C. 1437et. Seq., and the Housing and Community Development Act of 1981, P.L. 97-35, 85 stat., 348, 408 require applicants and residents to provide the other information listed in the first paragraph to the Authority. If you are, an applicant and you fail to give the Authority this information, the Authority may have to reject your application or delay action on it. If you are receiving Housing, assistance and you do not give the Authority the information the Authority may have to evict you or withdraw your housing assistance.

I have read and fully understand the Federal Privacy Act Statement.
Head of Household Signature *

Clear
Today's Date *

Month Day Year
Spouse/Co-Applicant Signature

Clear
Today's Date

Month Day Year
Other Member Over 18 Signature

Clear
Today's Date

Month Day Year

Authorization for the Release of Information/ Privacy Act Notice

to the U.S. Department of Housing and Urban Development (HUD) and the Housing Agency/Authority (HA)
Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of 1993. This law is found at 42 U.S.C. 3544.

This law requires that you sign a consent form authorizing: (1) HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits.

Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household's income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits.

Uses oflnformation to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return inforn1ation) force1iain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form.

Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age.

Persons who apply for or receive assistance under the following programs are required to sign this consent form:

PHA-owned rental public housing
Turnkey III Homeownership Opportunities
Mutual Help Homeownership Opportunity
Section 23 and 19(c) leased housing
Section 23 Housing Assistance Payments
HA-owned rental Indian housing
Section 8 Rental Certificate
Section 8 Rental Voucher
Section 8 Moderate Rehabilitation

Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA 's grievance procedures and Section 8 informal hearing procedures.

Sources of Information To Be Obtained

State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.)

U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self employment information and payments of retirement income as referenced at Section 6103(1)(7)(A) of the Internal Revenue Code.)

U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].)

Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in detern1ining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits.

Consent: I consent to allow HUD or the HA 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's assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it 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.

This consent form expires 15 months after signed.

Signatures:
Head of Household Signature *

Clear
Social Security Number, Head of Household *
If any
Today's Date *

Month Day Year
Spouse Signature

Clear
Today's Date

Month Day Year
Other Family Member over age 18 Signature

Clear
Today's Date

Month Day Year
Other Family Member over age 18 Signature

Clear
Today's Date

Month Day Year
Other Family Member over age 18 Signature

Clear
Today's Date

Month Day Year
Other Family Member over age 18 Signature

Clear
Today's Date

Month Day Year
Other Family Member over age 18 Signature

Clear
Today's Date

Month Day Year
Other Family Member over age 18 Signature

Clear
Today's Date

Month Day Year
Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C. 1437 et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C. 3601-19). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government's financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval.

Penalties for Misusing this Consent:

HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form.

Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD 9886. Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000.

Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or Improper use.
Should be Empty:

	Name	City, State	Telephone #	Account #
Gas Company
Electric Company
Water Company

Directions

APPLICATION PROCESS 2019

WHAT DO WE LOOK FOR IN BACK GROUND CHECKS?

Application for Admission

I. Applicant Information

II. Previous Information

III. Program Integrity

V. Employment/Income Information

VIII. References

IX. Certification of Information

U.S. Department of Housing and Urban (HUD) 2019 ANNUAL INCOME LIMITS

AUTHORIZATION FOR THE RELEASE OF INFORMATION

Authorization for the Release of Information/ Privacy Act Notice