Housing Application "*" indicates required fields 1Housing Information2Personal Information3Income Information4Current Housing5References6Documents & Certification Application Type* Affordable Home Affordable Rental Home Location*ChistochinaGulkanaRental Location*Cantwell – Cantwell ApartmentsChistochina – Chistochina ApartmentsChitina – Tarel ApartmentsCopper Center – Jim McKinley BuildingCopper Center – Wrangell View ManorGakona – Gakona ApartmentsGulkana – Gulkana ApartmentsMentasta – Shallow Water ApartmentsTazlina – Carol EstatesTazlina – C’Eynuui Lede ApartmentsTezdelende – Tezdelende ApartmentsGlennallen – Glennallen Campus Applicant Name* First Last 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 Applicant Email* Applicant PhoneApplicant Cell PhoneApplicant Work PhoneIs there a co-applicant?* Yes No Co-Applicant Name First Last Co-Applicant Email* Co-Applicant PhoneCo-Applicant Cell PhoneCo-Applicant Work PhoneTribal Affiliation*CantwellCopper CenterChitinaChistochinaGakonaGulkanaMentastaTazlinaOtherRegional Coporation*AhtnaOtherOther Tribal Affiliation*Other Regional Corporation*Family Composition Name Relationship Actions Edit Delete There are no Members. Add Member Maximum number of members reached. Is anyone in your immediate family related to any board of commissioners, staff of CRBRHA, or your village council members?* Yes No Please explain relationship.*Authorized Contacts Name Actions Edit Delete There are no Contacts. Add Contact Maximum number of contacts reached. Person’s other than signers authorized to receive information or updated information regarding your tenancy account. IncomeATAP* Yes No ATAP Monthly Amount*APA/GA* Yes No APA/GA Monthly Amount*SSI/SSA* Yes No SSI/SSA Monthly Amount*Pension/Retirement* Yes No Pension/Retirement Monthly Amount*Unemployment* Yes No Unemployment Monthly Amount*Child Support* Yes No Child Support Monthly Amount*Senior Assistance* Yes No Senior Assistance Monthly Amount*Veterans Pension* Yes No Veterans Pension Monthly Amount*Other Income* Yes No Other Monthly Amount*Co-Applicant ATAP* Yes No Co-Applicant ATAP Monthly Amount*Co-Applicant APA/GA* Yes No Co-Applicant APA/GA Monthly Amount*Co-Applicant SSI/SSA* Yes No Co-Applicant SSI/SSA Monthly Amount*Co-Applicant Pension/Retirement* Yes No Co-Applicant Pension/Retirement Monthly Amount*Co-Applicant Unemployment* Yes No Co-Applicant Unemployment Monthly Amount*Co-Applicant Child Support* Yes No Child Support Monthly Amount*Co-Applicant Senior Assistance* Yes No Co-Applicant Senior Assistance Monthly Amount*Co-Applicant Veterans Pension* Yes No Co-Applicant Veterans Pension Monthly Amount*Co-Applicant Other Income* Yes No Co-Applicant Other Monthly Amount*Alaska PFDDo all members in the household receive a PFD?* Yes No If not all household members receive a PFD, please explain who does not and why:*Employment InformationAre you employed?* Yes No Applicant Employer*Applicant Employer 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 Applicant Employer Phone*Applicant Employer FaxApplicant Occupation*Applicant SupervisorApplicant Wage*Applicant Weekly Hours*Is the co-applicant employed?* Yes No Co-Applicant Employer*Co-Applicant Employer 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 Co-Applicant Employer Phone*Co-Applicant Employer FaxCo-Applicant Occupation*Co-Applicant SupervisorCo-Applicant Weekly HoursCo-Applicant WagePayee & Case ManagementIs there a payee?* Yes No Payee Company*Payee Name* First Last Payee 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 Payee Phone*Is there case management?* Yes No Case Management Company*Case Manager Name* First Last Case Management 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 Case Manager Phone*Family AssetsAre there family assets?* Yes No Asset Types*Assets Value*BankingDo you have a banking account?* Yes No Name of Bank*Account Type* Checking Savings Checking Account Number*Savings Account Number*Criminal ConvictionHave you been convicted of a crime within the past 10 years?* Yes No Type of Crime*Have you been convicted of sexual assault?* Yes No If yes, what are your stipulations?* Statement of Current HousingCurrent Housing Status* I own a home I rent a home I am without a home Landlord Information First Last Landlord PhoneLandlord Email Current Housing Location* 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 If without a home, describe current housing arrangements.*Current Housing Condition* Housing is adequate Housing is substandard Housing is unsafe Current Housing Explanation*Please describe substandard or unsafe conditions. If current housing is adequate, please let us know why you are applying for housing. Credit HistoryI have had credit with the following creditors and authorize them to provide credit information to the Copper River Basin Regional Housing Authority for consideration regarding my application for Mutual Help or Low Rent Housing.Name of CreditorAccount NumberCreditor 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 Name of CreditorAccount NumberCreditor Address Street Address
