Housing Recertification Application "*" indicates required fields 1Personal Information2Income Information3Documents & Certification Form Type* Annual Interim Tenant Name* First Last 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 Tenant Email* Tenant PhoneTenant Cell PhoneTenant Work PhoneIs there a co-tenant?* Yes No Co-Tenant Name First Last Co-Tenant Email* Co-Tenant PhoneCo-Tenant Cell PhoneCo-Tenant 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. 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-Tenant ATAP* Yes No Co-Tenant ATAP Monthly Amount*Co-Tenant APA/GA* Yes No Co-Tenant APA/GA Monthly Amount*Co-Tenant SSI/SSA* Yes No Co-Tenant SSI/SSA Monthly Amount*Co-Tenant Pension/Retirement* Yes No Co-Tenant Pension/Retirement Monthly Amount*Co-Tenant Unemployment* Yes No Co-Tenant Unemployment Monthly Amount*Co-Tenant Child Support* Yes No Co-Tenant Child Support Monthly Amount*Co-Tenant Senior Assistance* Yes No Co-Tenant Senior Assistance Monthly Amount*Co-Tenant Veterans Pension* Yes No Co-Tenant Veterans Pension Monthly Amount*Co-Tenant Other Income* Yes No Co-Tenant 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 Tenant Employer*Tenant 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 Tenant Employer Phone*Tenant Employer FaxTenant Occupation*Tenant SupervisorTenant Wage*Tenant Weekly Hours*Is the co-tenant employed?* Yes No Co-Tenant Employer*Co-Tenant 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-Tenant Employer Phone*Co-Tenant Employer FaxCo-Tenant Occupation*Co-Tenant SupervisorCo-Tenant Weekly HoursCo-Tenant 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?* Release DocumentsPlease download this PDF and sign all pages. You can then either upload the signed document here or mail or drop it off to Copper River Basin Regional Housing Authority.Signed Release DocumentMax. file size: 50 MB.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.• Social Security cards for all members. • Certificates of Indian Blood (CIB) for all members. • Photo identification or Alaska drivers licenses for all adults. • Certificates of Live Birth for all members. Copies of documentation can be mailed to CRBRHA or dropped by offices.Certification* I/We certify that the information given to the Copper River Basin Regional Housing Authority on this recertification form is accurate and complete to the best of my knowledge and belief. I/We understand that false statements or information are punishable under Federal Law. I also understand that false statements or information are grounds for termination of housing assistance and termination of tenancy. I/We have no objection to inquires being made for the purpose of verifying the statements made herein.Tenant Signature*Co-Tenant Signature*NameThis field is for validation purposes and should be left unchanged.
