Application - Kenaitze Indian Tribe

Kenaitze/Salamatof TDHE
STU DE N T H O U SI N G
P.O. Box 988, Kenai, AK 99611
907-335-7230 * 907-335-7239 Fax
[email protected] * www.kenaitze.org
Application must be complete and supporting documents must be turned in within
30 days from the date the original written application was received.
Basic Guidelines are as follows:
1. Kenaitze/Salamatof Tribal member (preference), Alaska Native or American Indian
2. Meet income limits listed below
1
43,150
2
49,300
3
55,450
4
61,600
5
66,550
6
71,500
7
76,400
8
81,350
3. Need established
Annual Deadline for Application: August 1
The following is required to complete your application. If copies of verification are not
submitted in a timely manner applicant(s) may be denied.
Application form completely filled out, signed and dated
2014 tax form(s) that were submitted to the IRS
Income verification, pay stubs for the last two pay periods (if applicable)
Certificate of Indian blood
Copy of driver’s license
______
Social Security Card
Lease/Rental Agreement OR Dorm room expense
Proof of full-time enrollment
Most recent transcripts
Proof of pursuing a degree/certificate
Provide a completed FAFSA application
W-9 Form from current landlord
Kenaitze/Salamatof TDHE
STU DE N T H O U SI N G
P.O. Box 988, Kenai, AK 99611
907-335-7230 * 907-335-7239Fax
[email protected] * www.kenaitze.org
Student Housing Application
Please read and completely fill-out all questions to enable KIT/STC Housing to processing your
application. Use additional paper if necessary. Print or type.
GENERAL
email:
Applicant Last Name
First Name
MI
Contact Phone:
Co-Applicant Last Name
First Name
MI
Contact Phone:
Current Physical Address
Physical City
Physical State
Physical Zip
Mailing Address
Mailing City
Mailing State
Mailing Zip
Please list all persons who will be living in your home:
Name
Applicant
SSN
Marital Status
Gender
Age
Relationship
Co-Applicant
EMPLOYMENT
Applicant’s Current Employer
Applicant’s Employer Address
Date of hire
Applicant City
Co-applicant’s Current Employer
Co-applicant Employer’s address
May-15
Applicant State
Applicant Zip
Date of hire
Co-applicant City
-1-
Co-applicant State
Co-applicant Zip
INCOME
You must list all income earned or received by everyone listed on your application, including Native
Corporation income. This includes all income from wages, self-employment, child support, social
security, disability, longevity bonus, retirement income, worker’s compensation, etc. List gross
amounts received and attach verification for all income. (Note: If you are self-employed, that
income will be verified through your tax returns.) For more information about appropriate
verification, please see the last page of this application form.
Family member
Source of Income
Gross monthly income
Yearly income
Verification
attached











EDUCATION
Name of College/University
College Address
Student Status:
 Freshman
College City
Degree sought
 Sophomore  Junior  Senior
Applicant
Date
Co-applicant
May-15
College State
-2-
College Zip
Kenaitze/Salamatof TDHE
150 N. Willow St. / P.O. Box 988 Kenai, AK 99611
Phone: 907.335.7230 Fax: 907.335.7239
[email protected] * www.kenaitze.org
Student Housing Program
Participant Agreement
The Student Housing Program assists qualified participants with rental assistance during
their full-time attendance in an accredited college, university, or trade school, and pursuing a
degree/certificate. Kenaitze/Salamatof TDHE (TDHE) will continue providing assistance
throughout the current academic calendar year provided the student meets the program
requirements and continues to be a qualified low-income Alaska Native/American Indian
household with established residency in the TDHE jurisdiction (Kenai, Soldotna, Nikiski,
Sterling, and Kasilof north of the Kasilof River) and submits all requested documentation
throughout the school year in a timely manner as determined by the housing staff. Required
documentation may include, but shall not be limited to: a copy of official transcripts, lease
agreement, income verifications, and/or proof of enrollment.
I,
(Participant) understand that I will be required to submit
proof of full-time enrollment (12+ credits) before the beginning of each term. Failure to
submit required documentation will result in assistance being suspended. After proof is
provided assistance will continue on a prorated scale from the date the required
documentation was submitted to the TDHE. If at any point during the school year
Participant falls below 12 credits, he/she must report it to the TDHE IMMEDIATELY.
Failure to report student status change may result in future ineligibility and required payback
for assistance provided during Participant’s ineligibility period.
In addition, I,
(Participant) understand that I will be allowed
one month from the end of the term to provide proof of maintaining a 2.0 GPA or higher to
the housing staff. The TDHE shall provide assistance only after proof has been received
and the assistance amount will be provided on a prorated scale based on when the
documentation was submitted to the TDHE. If Participant drops below the minimum 2.0
GPA requirement the Participant will be placed on academic probation. Academic
probation will require the Participant to bring his/her GPA up to the required standard or
assistance will be cancelled.
Finally, I,
(Participant) understand that if there are any
income changes he/she is required to report and submit verification(s) within ten (10)
business days after the change has occurred. Failure to submit the required paperwork in a
timely manner will result in academic probation and Participant may be required to payback
a portion of the assistance.
By singing below Participant understands and agrees to the terms listed above.
Signature
May-15
Date
-3-
Kenaitze/Salamatof TDHE
150 N. Willow St. / P.O. Box 988 Kenai, AK 99611
Phone: 907.335.7230 Fax: 907.335.7239
[email protected] * www.kenaitze.org
Consent for Release of Confidential Information
Required for all household members 18 and older
I,
communication for
, authorize the mutual exchange of information and
□ Myself
□ My Child: ____________________________________________ (Child Legal Name)
□ As Legal Guardian/Power of Attorney on Behalf of:___________________________
between Kenaitze/Salamatof TDHE with Kenaitze Indian Tribe
AND:_______________________________________________________________________________
Name (if applicable) and Agency
I authorize the communication to be exchanged in writing, verbally, electronically, and/or other to
manage by plan. Initial each type of information you would like to be disclosed.
_____ History
_____ Income statements
_____ Financial statements
_____ School records/performance
_____ Verification of Indian Ancestry (CIB or Tribal Card)
_____ Lease/Rental Agreements
_____ Treatment plan/case plan
_____ Certificate of Birth/Death
_____ Medical records
_____ Verification of Native
Dividends
_____ Credit Report
_____ Landlord Reference
_____
Other
(Specify):_____________________________________________________________________
The above information is to be exchanged for the purpose of: Housing Services
Persons or organizations that may be contacted include, but are not limited to: the Department of
Public Assistance, Department of Law, the Department of Public Safety, the Department of Fish &
Game, the Department of Labor and Workforce Development, the Department of Military Affairs,
Alaska State Housing Authority, Social Security Administration, local and tribal governments, public
assistance program contractors and grantees, tax assessors, financial institutions, Native
corporations, stock brokerage firms, landlords, employers, school authorities, private individuals
and all departments and programs within and administered by the Kenaitze Indian Tribe.
I understand that some of my records are protected under the federal regulations governing
Confidentiality of Protected Health Information (HIPAA and 42 CFR, Part 2) and cannot be
disclosed without my written consent unless otherwise provided for in the regulations. I also
understand that I may revoke this consent at any time except to the extent that action has been
taken in reliance on it and that in any event this consent expires one year from date signed
unless otherwise stated as follows:
Signature of Client:______________________________________
May-15
-4-
Date:___________
Kenaitze/Salamatof TDHE
150 N. Willow St. / P.O. Box 988 Kenai, AK 99611
Phone: 907.335.7230 Fax: 907.335.7239
[email protected] * www.kenaitze.org
Income Statement
Applicant Name:
Directions: Please initial all that apply below. For example: If John B. Doe is Eligible for
Alaska Permanent Fund Dividends he would initial the line to the left as follows JBD I
am eligible for Alaska Permanent Fund Dividends. If a line item does not apply to your
situation please write N/A (Not Applicable).
I am not working or receiving wages from any source of employment.
I have no source of unearned income, i.e., cash benefits, gifts, etc..
I am eligible for Alaska Permanent Fund Dividends.
I have received Native Dividends within the last year.
I am not eligible for Alaska Permanent Fund Dividends.
By signing below the applicant agrees to and understands that if he/she begins employment
or starts to receive any other source of income that hasn’t already been reported to Housing
staff, he/she will notify Kenaitze/Salamatof TDHE within ten (10) business days and will
submit all requested documentation to verify income change(s) within fifteen (15) calendar
days of the notice. If income changes are not reported within the allotted time and
documentation is not submitted to Kenaitze/Salamatof TDHE Housing staff within the
allotted time Housing staff may choose to deny applicant(s) any further assistance.
Applicant Signature
May-15
Date
-5-
Things you should know
Purpose: This is to inform you that there is certain information you must provide when applying for assisted
housing. There are penalties that apply if you knowingly omit information or give false information.
Penalties for committing fraud: The United States Department of Housing and Urban Development places high
priority on preventing fraud. If your application forms contain false or incomplete information, you may be:
1. Required to repay all overpaid housing assistance you received
2. Fined up to $10,000.00
3. Imprisoned for up to five years
4. Prohibited from receiving future assistance
Your state and local government may have other laws as well.
Completing the application: When you give your answers to application questions, you must include the
following information:
1. All sources of money you and any adult member of your family receive
2. Any money you receive on behalf of your children
3. Income from assets
4. Earnings from second job or part time job
5. Any anticipated income
6. All bank accounts, savings, bonds, certificates of deposit, stocks, estate that are owned by you and any
adult member of your family who will be living with you
7. Any business or assets you sold in the last two years for less than its value, such as your home
8. The names of all the people who will actually be living with you, whether or not they are related to you
Signing the application: Do not sign any form unless you have read it, understand it, and are sure everything is
complete and accurate. When you sign application forms, you are claiming that they are complete to the best of
your knowledge and/or misleading information. Information you give on your application will be verified by your
Housing Agency. In addition, HUD may do computer matches of the income you report with various Federal, State,
or private agencies to verify that it is correct.
Beware of fraud: You should be aware of the following fraud schemes:
1. Do not pay any money to file application
2. Do not pay any money to move up on the application list
3. Do not pay anything not covered by your lease
4. Get a receipt for any money you pay
5. Get a written explanation if you are required to pay any money other than what your contract covers
Re-certifications: You must provide updated information at least once a year. Some programs require that you
report any changes in income or family composition immediately. You must report on recertification forms all
income changes, such as, pay increases or benefits, change of job, loss of benefits for all family members. You
must also report any family member who has moved in or out.
I understand that use of a photocopy of this release may be necessary to verify one or more of my references. I
authorize that use and request that such a copy be honored fully, as if it were an original. I understand that a
photocopy of this form will also serve as authorization.
I have read and understand this bulletin:
Signature
May-15
Date
-6-
Kenaitze/Salamatof TDHE
P.O. Box 988, Kenai, AK 99611
T: 907.335.7230 F: 907.335.7239
[email protected] * www.kenaitze.org
Budget Forecast
•
•
•
This form should be completed only after receiving results from Free
Application for Federal Student Aid (FAFSA).
The first page of this form is to be completed by the student. The second page
should be completed by the school Financial Aide Officer.
Once this form has been filled out in its entirety, the complete form should be
mailed or faxed back to Kenaitze Indian Tribe Attention: KIT Financial Aide
Officer
GENERAL
Last Name
First Name
Mailing Address
Marital Status
Number of dependants:
MI
Phone number
City
 Single
 Married
State
 Divorced
Zip
Separated
 Widow (er)
College/ University
Major/Emphasis
I have earned
Student ID
Forecasted graduation date:
credits to date. I plan to enroll for
credits this term.
I give my permission for the school listed above to give my financial information to the Kenaitze Indian Tribe’s
Educational, Employment and Training Department.
Applicant’s signature
May-15
Date
-7-
BUDGET FORECAST
*****This section should be completed by the school Financial Aide Officer*****
Forecast for term beginning:
and ending
Anticipated Resources
Anticipated Expenses
Alaska Native Scholarship
$
Tuition
$
BEOG
$
Fees
$
College/Univ. Scholarship
$
Dorm room deposit
$
Parent Contribution
$
Rent
$
Private Scholarship
$
Board
$
Salary/part-time employment
$
Meals
$
SEOG
$
Books
$
Social Security Administration
$
Supplies
$
State Student
$
Tools
$
Student Contribution
$
Tuition Grant (Alaska)
$
$
Veterans Administration
$
$
Vocational Rehabilitation
$
$
Work Study Scholarship
$
$
Workforce Investment
$
Total transportation expenses
Transportation (itemize)
Other expenses
Federal Resources
$
$
Federal Pell Grants
$
TOTAL EXPENSES
$
FSEOG
$
Subtract TOTAL RESOURCES
$
FWS
$
TOTAL NEED from BIA
$
Perkins Loans
$
Stafford Loans
$
SLS
$
Other resources
$
TOTAL RESOURCES
$
Student’s signature
Date
Financial Aide Officer
Date
May-15
-8-