BAHASTL’AH CHAPTER

HOUSING DISCRECTIONARY ASSISSTANCE

CHECK OFF LIST

(TO BE COMPLETED BY ADMINISTRATION)

Date Submitted:

Name:

Required documents for Assistance:

1. Housing Application

2. Map to Property

3. Signed Authorization for Release of Information form.

4. Copies of: Social Security card(s), CIB, Voters Registration card,

5. Copy of Home site lease and ownership of mobile home.

6. Material Listing & Three (3) Quotes, Cost Estimate from Vendors.

7. Home Assessment Completed by Chapter Personnel

HOME OWNER QUOTATIONS:

1. / 2. / 3. / 4.
$ / $ / $ / $

ASSESSMENT(S) / QUOTATION MADE BY CHAPTER PERSONNEL:

1. / 2. / 3. / 4.
$ / $ / $ / $

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ADMINISTRATION

Vendor: Amount of Check:

Date checked mailed: Last Assisted (date):

Fund Acct No.: Quote No.: Resolution No.:

APROVED DISAPPROVED PENDING

Note:

Chapter CoordinatorDateAccount Maintenance SpecialistDate

BAHASTL’AH CHAPTER

HOUSING DISCRETIONARY ASSISTANT APPLICATION

All questions should be completed to the best of your knowledge. Please attach photos and supporting document(s).

MUST BE ATTACHED TO APPLICATION

Copy of Certificate of Indian Blood (for all household members) / Copy of Home Site Lease
Copy of SS card(s) (for all household members) / Map to the location
Quotes: (3) three quote needed / Referrals

A) APPLICANT INFORMATION:

NAME: ADDRESS:

RESIDENTAL ADDRESS:

TELEHPHONE: CELL NO.:

CENSUS NO.: SSC NO.: DOB:

MARTIAL STATUS: ( ) SINGLE( ) MARRIED( ) WIDOWED( ) OTHER

SPOUSE NAME: CELL NO.:

CENSUS NO.: SSC NO.: DOB:

B) FAMILY INFORMATION:

Name / Relationship / Date of Birth / Census No.
1.
2.
3.
4.
5.

C) HOUSING INFORMATION:

  1. Electricity available? Name of Utility Company:
  2. Number of bedrooms: Bathroom facility: Indoor: Outside (only):
  3. Water Source: Private: Community Tank: Other:
  4. Have you been assisted with Housing Discretionary Assistance? If yes, please give date and the amount.

Date: Amount:

Date: Amount:

Did you submit all Receipts? . If no, please explain;

D) Explain your Assistant request (what happened? What you need? When it happened?

E) LAND INFORMATION:

What Land Status do you currently reside on:

[ ] Individual Trust Land[ ] Tribal Trust Land[ ] Individual Restricted

[ ] Tribal Fee Land[ ] Other(explain):

MAP TO HOME LOCATION:

Give direction(s) from Bahastl’ah Chapter to your location of your residence:

F) APPLICATION CERTIFICATION:

I certify that all information or answers given are true, complete and correct to the best of my knowledge and are made in good faith.

Applicant Signature Date Co-Applicant Signature Date

AUTHORIZATION FOR RELEASE OF INFORMATION:

I, hereby authorize the Navajo Nation through the Bahastl’ah Chapter to obtain all pertinent information to complete my application for Housing Discretionary Assistant. I understand and acknowledge this information will be used to determine by eligibility.

Signature of Applicant Date

NOTES:

HOME ASSESSMENT

Material Listing
Pictures / Photos
Others

DATE:

Name: Time:

Location of the Resident:

ASSESSMENT:

Materials Needed:

Project Coordinator DateCommunity Service Coordinator Date

1

HousingDiscretionaryFORM 11/2017