We May Be Able To Help You Rehab Your Home

Home Rehab

Application for Home Rehab

We are Here To Help!
Moriah McGill (707) 468-1336 Ext 112 moriah@nciha.org	Melodee Brusha (707) 468-1336 Ext 114 mbrusha@nciha.org

The Northern Circle Indian Housing Authority Board has established the following income limits to be eligible for our income based programs.

The income limits are based on household annual income and the number of household members.

Household Members	Annual Income Limit
1 Person	$44,744
2 People	$51,136
3 People	$57,528
4 People	$63,920
5 People	$69,034
6 People	$74,147
7 People	$79,261
8 People	$84,374

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

Step 1 of 9

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

Answer the following questions by checking the box if Yes

Leave the check box empty if your response the the question is no. Use the box if your need to further explain your response to the question.

What year was your home built?(Required)

Do you own your home?(Required)

If no, you are not eligible for our home rehab program.

Yes

Explain your ownership situation (optional)

Do you currently have homeowner's insurance?(Required)

If no, you are not eligible for our home rehab program.

Yes

Explain your homeowner's insurance situation (optional)

Is your home a manufactured home?

Yes

Provide more information if your home was manufactured.

Is your home on your Rancheria or Reservation?

Yes

Provide additional details about your home's location if necessary.

Have you ever received Housing REHAB assistance from NCIHA before? Please explain if Yes.

Yes

Provide details if you have received prior Home REHAB assistance from NCIHA

Do you have any outstanding debts with NCIHA or your Tribe? Please explain if Yes.

Yes

Provide specific information about any outstanding debts with your tribe or NCIHA.

Do you live in a home that is owned by your Tribal government, or that has been remodeld or constructed with BIA Housing Improvement Program (HIP), funding within the last 5 years?

Yes

Provide more information if your home is owned by your Tribal government, or if it was remolded/constructed with BIA HIP funding in the last 5 years.

Conflict of interest(Required)

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

Yes

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

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

HOUSING REHAB APPLICANT CERTIFICATION

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 REHAB 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

Home Rehab

Application for Home Rehab

Who Is Eligible

How do I apply

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

Answer the following questions by checking the box if Yes

Current Housing Information

Employment Income

Other Income

Applicant Certification and Acknowledgement

HOUSING REHAB APPLICANT CERTIFICATION

1. GIVING TRUE AND COMPLETE INFORMATION.

2. REPORTING CHANGES IN INCOME OR HOUSEHOLD COMPOSITION

3. REPORTING ON PRIOR HOUSING REHAB 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

CERTIFICATION