Form — H.I.P (Home Improvement Program) Application - Salish and Kootenai Housing Authority

Home Improvement Program (HIP)
*
I/we acknowledge that I/we reviewed, and agree to the Cover Letter.

Home Improvement Program (HIP)
Section A — Applicant Information
Applicant Information
All questions on this application MUST be filled in and answered. This application is subject to the Privacy Act of 1974, P.L # 93-579
Name*
First Middle Last
Current Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Message Number
Date of Birth*
Month
Day
Year
Social Security Number*
Enrolled Tribal Member?*
- Yes
- No
Name of Tribe
Enrollment #
Marital Status*
- Married
- Single
- Widowed
- Other
Spousal Information
Name
First Middle Last
Phone
Message Number
Date of Birth
Month
Day
Year
Social Security Number
Enrolled Tribal Member?
- Yes
- No
Name of Tribe
Enrollment #

Section B — Family Information
Family Information
List all person(s) living in the household on a permanent basis. Start with the oldest and provide social security numbers for all those 18 and older. (If you have more than one, click the + to the right to add more.)
*
Name D.O.B. SS# Relationship Enrollment#

Section C — Income Verification
Income Verification Earned income: Start with applicant/ self then list all permanent family members 18 years and older who are listed in Section B and have earned income, such as signed copy of SF-1040 (income tax), W2 forms, wages, stubs, etc. for verification.
Income Verification
Earned income: Start with applicant/ self then list all permanent family members 18 years and older who are listed in Section B and have earned income, such as signed copy of SF-1040 (income tax), W2 forms, wages, stubs, etc. for verification.
Name Annual Income Source of Income
Total Yearly Earned Income*
Attach earned income verification documents
Max. file size: 50 MB.
Unearned Income Start with applicant/ self then list all permanent family members 18 years and older who are listed in Section B and have unearned income. Example: Social Security, Retirement, Disability, Unemployment, Child Support/ Alimony, Royalties, Per Capita, Interest, Etc. Provide check stub statements, Individual Indian Monies (IIM) ledgers, etc.,. for verification.
Unearned Income
Start with applicant/ self then list all permanent family members 18 years and older who are listed in Section B and have unearned income.

Example: Social Security, Retirement, Disability, Unemployment, Child Support/ Alimony, Royalties, Per Capita, Interest, Etc. Provide check stub statements, Individual Indian Monies (IIM) ledgers, etc.,. for verification.
Name Annual Income Source of Income
Total Yearly Unearned Income*
Attach unearned income verification documents
Max. file size: 50 MB.
COMBINED ANNUAL INCOME TOTAL*
If anyone residing in your home, over the age of eighteen (18), regardless of relationship to the applicant, has no income, a No Income Declaration must be signed. You can obtain a No Income Declaration by contacting the Salish & Kootenai Housing Authority Home Improvement Program personnel and one will be mailed to you.

Section D — Housing Information
Physical Address*
Street Address Address Line 2 City State ZIP Code
Detailed directions of home that you are applying for repairs to be made:*
File Upload Area*
Proof of ownership with a legal description MUST be attached, and Home Owner Insurance.
Drop files here or

Max. file size: 50 MB.
Approximate age of home*
Size of home (Square Footage)*
Length (feet)*
Width (feet)*
Number of rooms*
Do you own the land which the home is located on?*
- Yes
- No
Do you know the status of the land?*
- Individual Trust
- Fee
- Tribal Restricted
- Tribal Trust
- Tribal Fee
- Do Not Know
Do you live in a mobile home?*
- Yes
- No
If so is it a double wide or modular?
- Double Wide
- Modular
Is the mobile home on a foundation?
- Yes
- No
Primary source of heat?*
- Electric
- Wood
- Propane
- Oil
Is electricity available?*
- Yes
- No
Type of sewer system?*
- City
- Septic
- Other
Water source?*
- City
- Well
- Community Water Tank
Bathroom facilities?*
- Yes
- No
Number of Facilities*
Bathrooms Bathtub Shower Sink Toilet
Have you received assistance from HIP previously?*
- Yes
- No
If yes, please give date, what was done, approximate amount of repairs, and to whom received the repairs:
Do you own any other property (house/land) that is NOT occupied by your family?*
- Yes
- No
If yes, state where the home/land is located and who occupies it:
Please provide a brief description of the home repairs which you are applying for or needing repaired:*

Section E — Household Health & Medical Information
Is anyone listed in sections A or B who is a permanent resident, have a severe health condition, handicapped, or *permanently disabled?*
- Yes
- No
If yes, please describe:
Is anyone listed in sections A or B who is a permanent resident have Asthma or any Respiratory conditions?*
- Yes
- No
If yes, please describe:
Is anyone is your household a United States Veteran?*
- Yes
- No
If so please provide a copy of your DD214 for verification, this will give you additional priority points:
Max. file size: 50 MB.
If a permanent resident has a medical condition, or disability please attach official documentation from their primary Medical Doctor. Or if receiving Social Security Disability/Veterans Administration Disability, please be sure to make note of this.
Max. file size: 50 MB.
If you have any other physical disability, or needs you this should be addressed, please write a brief statement below:

APPLICANT CERTIFICATION
READ THIS CERTIFICATION CAREFULLY BEFORE YOU SIGN AND DATE YOUR APPLICATION.
*
I/we acknowledge that I/we reviewed, and agree to the Criminal Drug Related Activity Policy.
To make false or misleading statements may constitute a violation of the 18 U.S.C.1001*
To make false or misleading statements may constitute a violation of the 18 U.S.C.1001
I declare that the information I have provided to the Salish & Kootenai Housing Authority if full, true and complete to the best of my knowledge. I hereby authorize the Salish & Kootenai Housing Authority to obtain any, and all, information that may be necessary for the purpose of verifying statements made in application for the Home Improvement Program. I acknowledge I have thoroughly read the attached Salish & Kootenai Housing Authority Criminal & Drug Related Activity Policy, and grant the Salish & Kootenai Housing Authority the authority to obtain any/all information necessary in confirming statements made, in verifying information submitted on application. Furthermore, I grant the Salish & Kootenai Housing Authority permission to obtain/release information necessary in assisting me to obtain other services for which I may be eligible and for determining eligibility for my eligibility in the Home Improvement Program.
Applicant Signature*
Date*
MM slash DD slash YYYY
Applicant Signature
Date
MM slash DD slash YYYY
PLEASE INITIAL THAT YOU HAVE READ THIS STATEMENT. It is very important you have a working telephone number, or a working message number, for us to be able to contact you. If you do not keep us updated if you change your telephone number, or have a working message phone number, this could possible delay your application for assistance, as it is important we are able to reach you.*

H.I.P (Home Improvement Program) Application

H.I.P (Home Improvement Program)

Step 1 of 7

Home Improvement Program (HIP)

Home Improvement Program (HIP)

Section A — Applicant Information

Spousal Information

Section B — Family Information

Section C — Income Verification

Section D — Housing Information

Section E — Household Health & Medical Information

APPLICANT CERTIFICATION

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Name	D.O.B.	SS#	Relationship	Enrollment#

Name	Annual Income	Source of Income

Name	Annual Income	Source of Income