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Apply for Assistance

Application For Services

We are Here To Help!
Christine De Los Santos (707) 468-1336 Ext 122 christine@nciha.org	Melodee Brusha (707) 468-1336 Ext 114 mbrusha@nciha.org
Katie Silva (707) 468-1336 Ext 118 ksilva@nciha.org	Montana Wise (707) 468-1336 Ext 116 mwise@nciha.org

Who is Eligible?
Must be an enrolled member of NCIHA's consortium
(membership verified)
Must be income-qualified to receive services (income is verified) Income Limits are available in link below

How do I apply?
You can apply below using our web application or by downloading the application and submitting it to NCIHA manually

NCIHA Applicaiton

Step 1 of 12 - Select Program(s) To Apply For

What are you applying for?

Please check each of the services which you are applying for.

Emergency Rental Assistance (ERAP)

Renters can receive up to 12 months of rental or utility payments to help ease financial issued cause by the COVID-19 pandemic.

Apply for Emergency Rental Assistance

Homeowner Assistance Fund (HAF)

Homeowners can apply for financial assistance with past due mortgage or utility payments resulting from financial difficulties related to the COVID-19 pandemic.

Apply for Homeowner Assistance

CARES Act

Emergency assistance for on or off Rancheria/Reservation, quarantine assistance, appliances, PPE (masks, gloves, etc), cleaning supplies, and food.

Apply for CARES Act emergency assistance

Rental Assistance

Apply to have a subsidy payment help you with your monthly rental charges in the private market.

Apply for Rental Assistance

On-Site Residency

Apply to live in a low-income home managed by NCIHA at your Reservation/Rancheria.

Apply for On-Site Housing

Deposit Assistance

A one time payment for a deposit for a rental in the private market.

Apply for Deposit Assistance

Waugh Lane Residency

Apply to live in an NCIHA owned and managed home located in Ukiah, CA

Apply for Waugh Lane Residency

Applicant Information

Applicant Name(Required)

First Last

Current Mailing Address(Required)

Street Address City State ZIP Code

County(Required)

Please enter the County you currently reside in.

Phone Number

Please enter your best contact number.

Email Address

Tribal Affiliation(Required)

Select your tribal affiliations. You, or a family member in your household, must be a member of one of the NCIHA consortium tribes to be eligible for NCIHA services.

Family member who is a consortium Tribe member(Required)

List the household member who is a member of the selected consortium tribe.

First Last

Tribal Roll Number(Required)

Applicant's Information

Applicant Birthdate(Required)

Gender(Required)

Applicant Social Security #(Required)

Check all that apply

Veteran

Disabled

Handicapped

Student (12+ units at college or voc ed school)

Elderly (62 or older)

Application Questions

Have you ever received housing assistance from NCIHA before? If yes, please explain

Do you have any outstanding debts with NCIHA or your tribe? If yes, please explain.

Do you currently rent in the private market?(Required)

Yes

Current Rent Amount(Required)

Landlord's Name(Required)

First Last

Landlord's Phone Number(Required)

Landlord's Address(Required)

Street Address City State ZIP Code

Conflict of Interest(Required)

Is the applicant, spouse, natural or adoptive child, parent, grandparent, grandchild, or sibling related to the NCIHA Board of Commissioners or staff? If yes, whom are you related to and what is the relationship?

Yes

List Relationships to NCIHA Board of Commissioners or staff(Required)

Covid Relief Questions

Answer the following questions if you are applying for the following programs which are related to the Covid-19 pandemic: ERAP, HAF, or CARES Act.

Qualifying Data for Covid-19 Assistance (Check all that apply)

Are you, or any family members of your household, age 65 or older?

Untitled

Do you, or any members of your household, have a qualifying medical condition that makes you vulnerable to Covid-19?

Untitled

Have you, or a family member of your household, experienced job loss or reduced hours du to the pandemic OR due to having to care for a child due to school closures?

If you checked any of the above Covid-19 qualifiers, please list below and attach all supporting documents. i.e. medical note, layoff notice, unemployment benefits, school notices, etc.(Required)

Explain in the space below why you may need food assistance. (Please be specific in what issues you may have)

Covid-19 Documentation

Upload any documentation related to your need for Covid-19 relief. Including, but not limited to, medical note, layoff notice, unemployment benefits, or school notices.

Max. file size: 100 MB.

Statement of Needs(Required)

Based on your responses to the Covid-19 questions above, please explain your specific needs in detail. This information will help determine eligibility and which programs you may qualify for.

I declare under penalty of perjury that I have fully, completely, and accurately answered all of the questions in this application, and that the information contained in this application is true and correct to the best of my knowledge. I agree that if I fail to disclose requested information, or if any of the information provided herein is inaccurate or incomplete, by omission or commission, NCIHA shall have the right to rescind my lease or mutual help agreement, and I shall immediately vacate the premises upon demand.

Applicant Signature(Required)

Manchester Point Arena Band of Pomo Indians

See Attached Resolution NO. 2008-105-120608
Have you, or a household member, been convicted of a serious crime such as but not limted to: murder; manslaugher; kidnapping; assault with a deadly weapon; marijuana cultivation; illegal possession of firearms; firing a gun in a negligent manner; burglary; theft; grand theft auto; drug possession; manufacturing, transportation, use and/or sales of illegal drugs; driving under the influence; domestic violence; elder abuse; child neglect or child abuse; sex offenses; or other crimes in the California Penal Code and California Vehicle code which pose a serious threat to the pease and savety of NCIHA projects.

Untitled(Required)

Yes

If yes, use the spaces below to list household member(s), and to explain the incident(s), charge(s), and outcome(s):(Required)

Hopland Band of Pomo Indians

Have you, or a household member, been arrested (18 and over) for or convicted of a serious crime such as but not limted to: murder; manslaugher; kidnapping; assault with a deadly weapon; marijuana cultivation; illegal possession of a firearm; firing a gun in a negligent manner; burglary, theft; grand theft auto; drug possession; manufacturing, transportation, use, and/or sales of illegal drugs; driving under the influence; domestic violence; elder abuse; child neglect or child abuse; sex offenses; welfare fraud; vandalism; diversion; embezzlement; and/or other which are enumerated in the California Penal Code and California Vehicle code and/or which pose a serious threat to the please and safety of NCIHA projects.

Untitled(Required)

Yes

If yes, use the space below to list the household member(s), explain the incident(s), charge(s), and outcome(s). (A criminal conviciton does not necessarily eliminate your from consideration)(Required)

This question does not apply to felonies. Please list misdemeanors if applicable.

Do you consent to allow NCIHA and/or HBPI to obtain information about your civil court and criminal history?(Required)

Failure to allow consent will eliminate you form consideration.

Yes

Employment Income

List the employer information for each family member employed.

Employer

Family Member Employed(Required)

First Last

Signature(Required)

Sign here to authorize your employer to release income information to NCIHA for the purpose of your application.

Social Security Number(Required)

Contact Person(Required)

Employer Phone Number(Required)

Employer Fax Number

Employer Email

Employer Address(Required)

Street Address City State ZIP Code

Employer

Family Member Employed(Required)

First Last

Signature(Required)

Sign here to authorize your employer to release income information to NCIHA for the purpose of your application.

Social Security Number(Required)

Contact Person(Required)

Employer Phone Number(Required)

Employer Fax Number

Employer Email

Employer Address(Required)

Street Address City State ZIP Code

Employer

Family Member Employed(Required)

First Last

Signature(Required)

Sign here to authorize your employer to release income information to NCIHA for the purpose of your application.

Social Security Number(Required)

Contact Person(Required)

Employer Phone Number(Required)

Employer Fax Number

Employer Email

Employer Address(Required)

Street Address City State ZIP Code

Other Income

List other income sources which are not from work such as (but not limited to) CalWORKS/TANF, Social Security, Disability, Veteran's Benefits, etc.

Agency Providing Benefit

Family Member Receiving Benefit(Required)

First Last

Signature(Required)

Sign here to authorize the agency providing benefits to release income information to NCIHA for the purpose of your application.

Social Security Number(Required)

Contact/Case Worker(Required)

Agency Phone Number(Required)

Agency Fax Number

Agency/Contact Email

Agency Address(Required)

Street Address City State ZIP Code

Agency Providing Benefit

Family Member Receiving Benefit(Required)

First Last

Signature(Required)

Sign here to authorize the agency providing benefits to release income information to NCIHA for the purpose of your application.

Social Security Number(Required)

Contact/Case Worker(Required)

Agency Phone Number(Required)

Agency Fax Number

Agency/Contact Email

Agency Address(Required)

Street Address City State ZIP Code

Agency Providing Benefit

Family Member Receiving Benefit(Required)

First Last

Signature(Required)

Sign here to authorize the agency providing benefits to release income information to NCIHA for the purpose of your application.

Social Security Number(Required)

Contact/Case Worker(Required)

Agency Phone Number(Required)

Agency Fax Number

Agency/Contact Email

Agency Address(Required)

Street Address City State ZIP Code

Applicant Certification and Acknowledgement

APPLICANT CERTIFICATION AND ACKNOWLEDGEMENT

1. GIVING TRUE AND COMPLETE INFORMATION.

I certify all the information provided on this application is accurate and complete to the best of my knowledge. I have reviewed all applicable NCIHA forms and certify the information shown is correct.

2. REPORTING CHANGES IN INCOME OR HOUSEHOLD COMPOSITION

I understand I am required to report changes in income and any changes in the household size when a person moves in or out of the unit. I understand the rules regarding guests/visitors, and when I must report anyone who is stying with me.

3. REPORTING ON PRIOR HOUSING ASSISTANCE

I certify I have disclosed where and when I received any previous federal housing assistance and whether or not any money is owed. I certify that for this previous assistance I did not commit any fraud, knowingly misrepresent any information, or vacate the unit in violation of the lease.

4. NO DUPLICATE RESIDENCES OR ASSISTANCE

I certify the house or apartment will be my principle residence, and I will not obtain duplicate federal housing assistance while I am in this current program.

5. NO OWNERSHIP INTEREST IN ANOTHER HOME WHICH I COULD USE AS A RESIDENCE

I certify I do not own any interest in a house, condominium, cooperative, or building which I could use as a residence, and that I am currently in need of decent, safe, and sanitary housing. If I acquire an ownership interest in a residence while I am renting a house or apartment from NCIHA, I agree to notify NCIHA immediately. Further, I understand NCIHA may terminate my lease based on my ownership interest in a residence. I agree to vacate the house or apartment I am renting from NCIHA immediately if NCIHA terminates my lease because I have acquired an interest in a residence.

6. COOPERATION

I know I am required to cooperate in the supplying of all information needed to determine my eligibility, level of benefits, or verify my true circumstances. Cooperation includes attending pre-scheduled meetings and completing and signing needed forms. I understand failure, or refusal to do so, may result in delays, termination of assistance, or eviction.

7. CRIMINAL AND ADMINISTRATIVE ACTION FOR FALSE INFORMATION

I understand that knowingly supplying false, incomplete, or inaccurate information is punishable under federal or state criminal law. I understand that knowingly supplying false, incomplete, or inaccurate information is grounds for termination of housing assistance and/or termination of tenancy.

8. TRIBAL MEMBERSHIP

I certify that I, or a member of my household, is a current member of one of the NCIHA consortium tribes. If applying for on-site housing or Tribe specific assistance, I certify that I, or a member of my household, is a current member of the applicable Tribe.

9. NO OUTSTANDING DEBTS

I certify I do not have any outstanding debts with NCIHA or my Tribe. Any outstanding debts must be resolved before I am eligible for assistance with NCIHA.

CERTIFICATION OF APPLICANT FAMILY MEMBERS

All Adult (18 Years or Older) Members of Household Required to Sign Below

I certify I have read and understand the declarations listed above. I also certify the information I have provided is true to the best of my knowledge, and understand that any misrepresentations of information or false statements shall be grounds for termination of Lease/MHOA.

Applicant Signature(Required)

Signature attesting to the truthfulness and accuracy of this application.

Applicant Signature Date(Required)

Spouse or Partner's Signature

Signature attesting to the truthfulness and accuracy of this application.

Spouse or Partner's Signature Date

Adult Family Member 1 Signature

Signature attesting to the truthfulness and accuracy of this application.

Adult Family Member 1 Signature Date

Adult Family Member 2 Signature

Signature attesting to the truthfulness and accuracy of this application.

Adult Family Member 2 Signature Date

Adult Family Member 3 Signature

Signature attesting to the truthfulness and accuracy of this application.

Adult Family Member 3 Signature Date

Adult Family Member 4 Signature

Signature attesting to the truthfulness and accuracy of this application.

Adult Family Member 4 Signature Date

Authorization for the Release of Information/Privacy Act Notice

This is a digital reproduction of HUD form 9886.

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 verifi-cation of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensa-tion 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 of Information 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 information) for certain 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 im-proper 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.

U.S. Department of Housing and Urban Development

Office of Public and Indian Housing

Northern Circle Indian Housing Authority
694 Pinoleville Dr.
Ukiah, CA 95482
(707) 468-1336

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 termi-nation 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 re-ceived 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 pay-ments of retirement income as referenced at Section 6103(l)(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 divi-dends). I understand that income information obtained from these sources will be used to verify information that I provide in determining 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.

Applicant Signature(Required)

Signature to allow the release of information to NCIHA.

Applicant Signature Date(Required)

Spouse or Partner Signature

Signature to allow the release of information to NCIHA.

Spouse or Partner Signature Date

Adult Family Member 1 Signature

Signature to allow the release of information to NCIHA.

Adult Family Member 1 Signature Date

Adult Family Member 2

Signature to allow the release of information to NCIHA.

Adult Family Member 2 Signature Date

Adult Family Member 3 Signature

Signature to allow the release of information to NCIHA.

Adult Family Member 3 Signature Date

Adult Family Member 4 Signature

Signature to allow the release of information to NCIHA.

Adult Family Member 4 Signature Date

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.

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.

Apply for Assistance

Application For Services

NCIHA Applicaiton

What are you applying for?

Applicant Information

Applicant's Information

Household Members Information

Spouse or Partner Information

Additional Family Member 1 Information

Additional Family Member 2 Information

Additional Family Member 3 Information

Additional Family Member 4 Information

Additional Family Member 5 Information

Application Questions

Covid Relief Questions

Manchester Point Arena Band of Pomo Indians

Hopland Band of Pomo Indians

Current Housing Information

Employment Income

Other Income

Applicant Certification and Acknowledgement

APPLICANT CERTIFICATION AND ACKNOWLEDGEMENT

1. GIVING TRUE AND COMPLETE INFORMATION.

2. REPORTING CHANGES IN INCOME OR HOUSEHOLD COMPOSITION

3. REPORTING ON PRIOR HOUSING ASSISTANCE

4. NO DUPLICATE RESIDENCES OR ASSISTANCE

5. NO OWNERSHIP INTEREST IN ANOTHER HOME WHICH I COULD USE AS A RESIDENCE

6. COOPERATION

7. CRIMINAL AND ADMINISTRATIVE ACTION FOR FALSE INFORMATION

8. TRIBAL MEMBERSHIP

9. NO OUTSTANDING DEBTS

CERTIFICATION OF APPLICANT FAMILY MEMBERS

Authorization for the Release of Information/Privacy Act Notice

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)

U.S. Department of Housing and Urban Development

Office of Public and Indian Housing