Housing Preservation Application "*" indicates required fields 1Personal Information2Property Information3Documents & Certification Name* First Last Date of Birth* MM slash DD slash YYYY Email* Physical Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address* Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home PhoneCell PhoneWork PhoneTribal Affiliation*CantwellCopper CenterChitinaChistochinaGakonaGulkanaMentastaTazlinaOtherRegional Corporation*AhtnaOtherOther Tribal Affiliation*Other Regional Corporation*Are you a Veteran?* Yes No Date of Service*Branch*Type of Discharge*Family Composition Name Relationship Actions Edit Delete There are no Members. Add Member Maximum number of members reached. Income Source(s)Please fill in the dollar amount for the type of income you have received for the last 30 days. The annual income, fill in the dollar amount you have received for the last 12 months. Please provide income verification (i.e. pay stubs, retirement benefits, social security, etc.)Earned Income – Last 30 DaysEarned Income – Last 12 MonthsUnemployment – Last 30 DaysUnemployment – Last 12 MonthsTANF/ATAP – Last 30 DaysTANF/ATAP – Last 12 MonthsGeneral Assistance (GA) – Last 30 DaysGeneral Assistance (GA) – Last 12 MonthsSocial Security Income – Last 30 DaysSocial Security Income – Last 12 MonthsChild Support – Last 30 DaysChild Support – Last 12 MonthsAlimony Support – Last 30 DaysAlimony Support – Last 12 MonthsFoster Care Payments – Last 30 DaysFoster Care Payments – Last 12 MonthsAlaska Permanent Dividend – Last 30 DaysAlaska Permanent Dividend – Last 12 MonthsNative Corporation Dividends – Last 30 DaysNative Corporation Dividends – Last 12 MonthsVA Payments – Last 30 DaysVA Payments – Last 12 MonthsRetirement Benefits – Last 30 DaysRetirement Benefits – Last 12 MonthsOther Income – Last 30 DaysOther Income – Last 12 MonthsCurrent EmploymentApplicant Job TitleApplicant EmployerApplicant Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Applicant Employer ContactCo-Applicant Job TitleCo-Applicant EmployerCo-Applicant Employer Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Co-Applicant Employer Contact Do you own the house to be repaired?* Yes No Location of House to be Repaired, Constructed, or Purchased* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Year House Was Constructed*Number of Bedrooms*House Length*House Width*House Square Feet*Flush Toilet?* Yes No Kitchen Sink?* Yes No Electricity?* Yes No Power Company*Sewer System* Community System Septic Tank Chemical Toilet Water Source* Community System Private Well Other Do you own any other house that you do not live in?* Yes No If yes, please explain where the house is located and why you do not use it.*Is this a rental unit?*If a rental unit, you must provide a letter from Landlord authorizing repairs, a current tax return or income from the Landlord, and a Certificate of Degree of Indian Blood. Yes No Do you own the land on which you wish to renovated or build this home?* Yes No Land Owner Name* First Last Land Owner PhoneLand Owner Mailing Address* Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code What status is the land now listed in?* Individual Trust Tribal Trust Tribal Restricted Individually Restricted (Allotment) Tribal Fee Simple Fee Patented Other If you do not own the land, do you have?* A 25 Year Leasehold Interest Use Permit Indefinite Assignment of Joint Ownership Other Insurance InformationIn accordance to 24 CFR Part 1000.136 requires homeowners to carry insurance on any project that is assisted with a NAHASDA grant over $5,000. Please provide the following insurance information. CRBRHA must be placed on existing or new policy as a secondary insured. This allows CRBRHA to file a claim on your insurance if the structure is destroyed or extensively damaged by fire, flood, etc.Name of Insurance CompanyInsurance Company Adress Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Insurance Company PhonePolicy Number Applicant's NarrativePlease list what you need done for your Modernization/Rehabilitation project. Please keep in mind that the limit is $10,000.00 total for Homes and $5,000.00 total on trailers/mobile homes. This will include labor paid in accordance with CRBHRA Tribally Prevailing Wages rate schedule for the contractor and their crew as well as the cost of materials. Therefore you must prioritize and list in order of what you need done followed by what you would like done. Bidding will got out based on the order of priority and what you have listed here.Proposed Material List Material Description Quantity Actions Edit Delete There are no Materials. Add Material Maximum number of materials reached. Additional Documentation* I understand that I must supply the following information and that providing false information will disqualify me from receiving any type of assistance from CRBRHA and can result in legal action.• Previous years signed income tax forms with 1099’s and W-2’s. If you do NOT file you must have a letter from IRS stating that you are not required to file. • Proof of Income for the entire household for the last 12 months • Proof of Homeowners insurance • Divorce Decree, if applicable • BIA or Certificate of Indian Blood or Tribal Enrollment Card • Picture ID or a valid Driver’s License or Passport • If disabled – Proof of disability from doctor or other legal source stating disability • Quit Claim, Warranty Deed or title for home to be worked on. Copies of documentation can be mailed to CRBRHA or dropped by offices.Applicant Certification* I hereby certify that all information made on or in connection with this application is true and complete to the best of my knowledge. I understand that if I deliberately enter false information on this form, I may receive a $10,000 fine, imprisonment for not more than two (2) years, or both. I also understand that any misrepresentation or concealment of material fact will be sufficient grounds for rejection of my application, removal from any eligibility list, or suspension from any CRBRHA program participation and services.Conflict of Interest Certification* I hereby certify and disclose any potential Conflict of Interest between my application and staff of CRBRHA, or a Commissioner of CRBRHA or an officer or council member of my respected village. The following is a statement of who the applicant is related to either a member of the Board of Commissioners, staff or a Village Council member.Conflict of Interest StatementRelease of Information* I, hereby authorize the release of any information concerning me, to the Copper River Basin Regional Housing Authority located at Mile 111 Richardson Highway, PO Box 89, Glennallen, Alaska 99588. The requested information shall be used solely in the administration of CRBHRA programs, and a reproduction of this release is as valid as the original. This authority shall continue until revoked in writing by the undersigned.Contacts may include but are not limited to: • Public Assistance • Department of Labor • Social Security Administration • Veteran’s Administration • Division of vocation Rehabilitation (DVR) • Employers • Native Corporations • Child Support Enforcement Agency • Bureau of Indian Affairs • Private Individuals • Alaska Permanent Fund Dividend Fund • Alaska Longevity Fund • Copper River Native AssociationApplicant's Statement*Spouse/Significant Other Signature
