Form — FFP Application - Salish and Kootenai Housing Authority

FFP Application July 2019

Flathead Finance Program Application Checklist

Step 1 of 9

Flathead Finance Program Application
Please be sure to enter all information to ensure your application is complete. Applications that are incomplete will be returned.

Please be aware that pending the type of assistance you are requesting you may be required to provide additional information to help us determine assistance.
TYPE OF ASSISTANCE APPLYING FOR:*
Please mark all types of assistance you are requesting.
- Down Payment
- Closing Cost
- Tribal Credit Referral
- Inspection
- Credit Repair
- Budgeting
- Foreclosure
HOUSEHOLD COMPOSITION
Household Composition*
Please list the head of household and all other persons who will be living in your home. Give the relationship of each family member to the head of household. EACH HOUSEHOLD MEMBER AGE 18 YEARS AND OLDER MUST HAVE FULL MIDDLE NAME ON FORM AND SIGN THIS APPLICATION.
Full Name Marital Status Relation to HOH Date of Birth Gender (M/F) Social Security # Tribal Affiliation
Upload Proof of Enrollment (copy of Tribal ID)
(If you're an enrolled Tribal member)
Max. file size: 50 MB.
Upload Copy of State ID or State Driver's License
Max. file size: 50 MB.
CONTACT INFORMATION
Address*
Street Address Address Line 2 City State ZIP Code
Home Phone
Mobile*
Email*
Work Phone
Fax
Are you able to receive calls & faxes at work?*
- Yes
- No
Is English your primary language?*
- Yes
- No
ADDITIONAL CONTACT INFORMATION
Name*
This information is used only in the event we are unable to reach you at the contact information you provided above.
First Last
Relationship*
Phone*
Address*
Street Address Address Line 2 City State ZIP Code

SIGNATURES
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 borrower under its program. It will not be disclosed outside the 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 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 et. Seq. (if HUG/FHA); by 42 USC, Section 145b (if HUD/CPD); and Tile 42 USC, 1471 et, SEW., or 7 USC, 1921 et. Seq. (if USDA/FmHa).

I/We hereby affirm that the foregoing information is true and complete to the best of my/our knowledge, and authorize the Flathead Finance Program to make inquiries to verify the statements herein. I/We further understand that any intentional misrepresentation in this application might result in default and/or eviction of this household. If any of the aforementioned information changes, I/we agree to notify immediately.
Please print your FULL LEGAL NAME below*
Add additional applicants by clicking the "+" icon on the right.
Applicant Social Security Number
Notice of Penalty for Misrepresentation*
I agree and have read Notice of Penalty For Misrepresentation.*
SKHA Criminal and Drug Related Activity Policy*
I have read and accept the terms of the SKHA Criminal and Drug Related Activity Policy.*
A COPY OF THIS AUTHORIZATION MAY BE ACCEPTED AS AN ORIGINAL*
I/we grant Salish & Kootenai Housing Authority permission to release information necessary in assisting me in obtaining other services for which I may be eligible.
I have read and understand the regulations on this Signatures PDF.
Applicant’s Signature*
Date*
MM slash DD slash YYYY
Additional Applicant’s Signature
Date
MM slash DD slash YYYY
Additional Applicant’s Signature
Date
MM slash DD slash YYYY

Authorization to Release Information
THIS RELEASE OF INFORMATION IS GOOD FROM ONE YEAR FROM THE DATE SIGNED.
Authorization to Release Information*
I (We) hereby authorize Salish & Kootenai Housing Authority (SKHA), to verify my employment, and outstanding debt, including my present or previous mortgages, and to make any other inquiries pertaining to the Counseling Services they are providing to me, at their request.
Mortgage Lenders/Servicers*
I (We) hereby authorize Salish & Kootenai Housing Authority (SKHA), to obtain any and all information about my account. I understand that information released to SKHA, may include, but is not limited to, information relating to my loan amount and payment transactions and/or the provision of copies of my loan documents.
Information Release*
I (We) herby authorize Salish & Kootenai Housing Authority (SKHA), to obtain any and all information released to SKHA, may include, but is not limited to, information relating to any loan modification, forbearance plan and repayment, transactions and/or the provision of copies of my loan documents.
I acknowledge that this authorization will remain in effect for the duration of time necessary to help me address my financial problems. SKHA will also assist in proposing a loss mitigation plan that is within your guidelines. I also acknowledge that should I wish to terminate this authorization, I will notify you in writing.*
1st Mortgage Loan Number
Authorized Third Party: SALISH & KOOTENAI HOUSING AUTHORITY PO Box 38 Pablo, MT 59855 Telephone: (406)675-4491 Fax: (406)675-4495
Applicant Name (Print)*
First Last
Applicant Signature*
Date*
MM slash DD slash YYYY
Social Security Number*
Co-Applicant Name (Print)
First Last
Co-Applicant Signature
Date
MM slash DD slash YYYY
Social Security Number

Program Disclosure Form
NOTE: If you have an impairment, disability, language barrier, or otherwise require an alternative means of completing this form or accessing information about housing counseling, please talk to your housing counselor about arranging alternative accommodations.
Program Disclosure Form*
I have read and agree to the Client and Counselor Roles and Responsibilities in the Program Disclosure form.
FFP Privacy Policy*
Please initial acknowledging that you have received a copy of The Flathead Finance Program’s Privacy Policy.
HUS-92564-CN & Important Questions*
Please initial and sign below acknowledging that you have received a copy of “For Your Protection: Get a Home Inspection” (HUD-92564-CN) & “Ten Important Questions to Ask Your Home Inspector”.
Name 1 Signature*
I/we acknowledge that I/we received, and agree to the Flathead Finance Program Disclosures.
Date*
MM slash DD slash YYYY
Name 2 Signature
I/we acknowledge that I/we received, and agree to the Flathead Finance Program Disclosures.
Date
MM slash DD slash YYYY
Counselor Signature
Date
MM slash DD slash YYYY

Privacy Policy
Please read the Privacy Policy then select one(1) option below:
Privacy Policy*
- OPT-OUT: I request that The Flathead Finance Program make no disclosures of my nonpublic personal information to third parties other than project partners and those permitted by law. By choosing this option, I understand that The Flathead Finance Program will NOT be able to answer any questions from my creditors. I understand that I may change my decision at any time by contacting The Flathead Finance Program.
- RELEASE: I hereby authorize The Flathead Finance Program to release nonpublic personal information it obtains about me to my creditors and any third parties necessary to provide me with the services I requested. I acknowledge that I have read and understand the above privacy practices and disclosures.
Printed Name 1*
First Last
Signature 1*
Date*
MM slash DD slash YYYY
Printed Name 2
First Last
Signature 2
Date
MM slash DD slash YYYY

PRIVACY POLICY AND PRACTICES OF SALISH & KOOTENAI HOUSING AUTHORITY
SKHA Privacy Policy and Practices*
I have read and agree to PRIVACY POLICY AND PRACTICES OF SALISH & KOOTENAI HOUSING AUTHORITY.*
Signature*
Date*
MM slash DD slash YYYY
Signature
Date
MM slash DD slash YYYY

HOUSING COUNSELOR/CLIENT AGREEMENT
Housing Counselor/Client Agreement*
I have read and agree to the terms of service in the HOUSING COUNSELOR/CLIENT AGREEMENT.*
Applicant Name*
First Last
Signature*
Date*
MM slash DD slash YYYY
Counselor Name
First Last
Co-Applicant Name
First Last
Co-Applicant Signature
Date
MM slash DD slash YYYY
Counselor Signature
Date
MM slash DD slash YYYY

EMPLOYMENT VERIFICATION
Employer Name*
Applicant Name*
First Last
Social Security Number*
Upload Employer Verification Form*
Please send this Employer Verification Form to your employer, then upload the completed PDF below using the upload area.
Max. file size: 50 MB.
Signature*
PERMISSION FOR RELEASE OF INFORMATION
You do not have to sign this form if either the requesting organization or the organization apply the information is left blank. RELEASE: I hereby authorize the release of the requested information. Information obtained under this consent is limited to information that is no older than 12 months. There are circumstances which would require the owner to verify that is up to 5 years old, which would be authorized by me on a separate consent, attached to a copy of this consent.
Date*
MM slash DD slash YYYY

Name of Employer	Address	Telephone	Date of Employment (Start)	Job Title	Supervisor	Rate of Pay	Hours Per Pay Period

FFP Application

FFP Application July 2019

Step 1 of 9

Flathead Finance Program Application

HOUSEHOLD COMPOSITION

CONTACT INFORMATION

ADDITIONAL CONTACT INFORMATION

EDUCATIONAL LEVEL

GENERAL QUESTIONS

EMPLOYMENT INFORMATION

MONTHLY EXPENSES

SIGNATURES

Authorization to Release Information

Program Disclosure Form

Privacy Policy

PRIVACY POLICY AND PRACTICES OF SALISH & KOOTENAI HOUSING AUTHORITY

HOUSING COUNSELOR/CLIENT AGREEMENT

EMPLOYMENT VERIFICATION

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Full Name	Marital Status	Relation to HOH	Date of Birth	Gender (M/F)	Social Security #	Tribal Affiliation

PAID TO	MONTHLY BILL AMOUNT	TOTAL AMOUNT DUE

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