Pre-qualification application Form

Cahuilla Band of Indians
ICDBG Housing Pre-qualification Application

Pre-qualification application instructions

APPLICATIONS CAN BE REQUESTED AT THE TRIBAL ADMINISTRATION OFFICE DURING BUSINESS HOURS, BY EMAILING THE HOUSING AUTHORITY AT [email protected] OR ACCESSING THE APPLICATION VIA THE CAHUILLA WEBSITE
APPLICATION MUST BE FILLED OUT COMPLETELY (ANY INCOMPLETE APPLICATION WILL NOT BE ACCEPTED)
MUST SIGN & DATE THE APPLICATION
MUST HAVE A CURRENT CONTACT PHONE NUMBER AND ADDRESS
TO SUBMIT APPLICATIONS: VIA EMAIL TO [email protected], FAX TO (951) 763-2808 OR MAIL/WALK IN TO THE ADDRESS BELOW:
Cahuilla Housing Committee
52701 Hwy 371
Anza, Ca 92539
IF YOU HAVE ANY QUESTIONS ABOUT THE APPLICATION PLEASE EMAIL THE HOUSING AUTHORITY AT [email protected]

"*" indicates required fields

APPLICANTS INFORMATION

This pre-qualification application is to determine eligibility only. A more detailed application will be required with supporting documentation upon selection of applicants.

NAME*

First Middle Last

Tribal ID #*

CURRENT ADDRESS*

Street Address Address Line 2 City State ZIP Code

MAILING ADDRESS

Street Address Address Line 2 City State ZIP Code

PHONE NUMBER

DATE OF BIRTH

MARITAL STATUS

IF OTHER, PLEASE EXPLAIN

SPOUSE INFORMATION

NAME

First Middle Last

CURRENT ADDRESS

Street Address Address Line 2 City State ZIP Code

PHONE NUMBER

DATE OF BIRTH

LIST OF CHILDREN OR DEPENDENTS THAT WILL BE LIVING IN THE HOME:

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

LIST OF ADULTS (OTHER THAN APPLICANT) THAT WILL BE LIVING IN THE HOME:

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

NAME

DOB

AGE

RELATIONSHIP TO APPLICANT

INCOME INFORMATION:

EARNED INCOME:
START WITH APPLICANTS INCOME FIRST, THEN THE INCOME OF ANY INDIVIDUALS LISTED ABOVE.

NAME

ANNUAL INCOME

SOURCE OF INCOME

NAME

ANNUAL INCOME

SOURCE OF INCOME

NAME

ANNUAL INCOME

SOURCE OF INCOME

NAME

ANNUAL INCOME

SOURCE OF INCOME

NAME

ANNUAL INCOME

SOURCE OF INCOME

NAME

ANNUAL INCOME

SOURCE OF INCOME

NAME

ANNUAL INCOME

SOURCE OF INCOME

UNEARNED INCOME:
START WITH APPLICANTS INCOME FIRST, THEN THE INCOME OF ANY INDIVIDUALS LISTED ABOVE.

NAME

ANNUAL UNEARNED INCOME

SOURCE OF INCOME

NAME

ANNUAL UNEARNED INCOME

SOURCE OF INCOME

NAME

ANNUAL UNEARNED INCOME

SOURCE OF INCOME

NAME

ANNUAL UNEARNED INCOME

SOURCE OF INCOME

NAME

ANNUAL UNEARNED INCOME

SOURCE OF INCOME

NAME

ANNUAL UNEARNED INCOME

SOURCE OF INCOME

NAME

ANNUAL UNEARNED INCOME

SOURCE OF INCOME

APPLICANT CERTIFICATION

(Read this certification carefully before you sign and date your application.).

I certify that all the answers given are true, complete and correct to the best of my knowledge and belief, and they are made in good faith. This certification is made with the knowledge that the information will be used to determine eligibility to receive financial assistance, and that false or misleading statements may constitute a violation of 18 U.S.C. 1001. This application contains materials covered by the Privacy Act. No record will be communicated to anyone or any agency unless requested in writing, either by the applicant or an officer or employee of the housing program or other Federal agency requiring it in the performance of their duties.

Applicant's Signature

Date

Spouse's Signature (if appropriate)

Date

This field is for validation purposes and should be left unchanged.

PRIVACY ACT STATEMENT

Part 256 of CFR, established under the mechanism of the Snyder Act, 25 USC 13, provides for the collection of this information. The primary use of this information is by an officer or employee of the Federal or Tribal housing office to determine eligibility for a grant for services provided under the Housing program. Additional disclosures of the information may be: to a Housing and Urban Development employee or Bureau of Indian Affairs employee in the conduct of a program review or audit: or to a federal law enforcement agency when the agency becomes aware of violation or possible violation of civil or criminal law. Furnishing the information on this form is required to establish eligibility for your participation in the program.

PAPERWORK REDUCTION ACT STATEMENT

This information is being collected to select eligible families or individuals to participate in the housing program. You are not required to respond to this collection of information unless if displays a currently valid OMB control number. This information will be used to determine the eligibility and the ranking of the applicant. Response to this request is required to obtain a grant for services in accordance with 25 CFR 256.

ESTIMATED BURDEN STATEMENT

Public reporting burden for ^–Ibis_. form is estimated to average 30 minutes per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to Housing and Urban Development or Bureau of Indian Affairs, information Collection Center, 1849 C. Street, N.W. Washington, D.C. 20240.

Contact Information

Cahuilla Band of Indians
52701 US Hwy 371
Anza, CA 92539

Phone | (951) 763-5549
Fax | (951) 763-2808

Pre-qualification application Form

Cahuilla Band of IndiansICDBG Housing Pre-qualification Application

Pre-qualification application instructions

APPLICANTS INFORMATION

SPOUSE INFORMATION

LIST OF CHILDREN OR DEPENDENTS THAT WILL BE LIVING IN THE HOME:

LIST OF ADULTS (OTHER THAN APPLICANT) THAT WILL BE LIVING IN THE HOME:

INCOME INFORMATION:

APPLICANT CERTIFICATION

PRIVACY ACT STATEMENT

PAPERWORK REDUCTION ACT STATEMENT

ESTIMATED BURDEN STATEMENT

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Cahuilla Band of Indians
ICDBG Housing Pre-qualification Application