BIA Form 6407

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BIA Form 6407	OMB Control No. 1076-0184 
ISSUED [Insert date]									          EXPIRATION DATE: [insert date]

UNITED STATES DEPARTMENT OF THE INTERIOR
BUREAU OF INDIAN AFFAIRS
HOUSING ASSISTANCE APPLICATION

    • All questions in this application must be answered.  The requested information is self-explanatory.
    • This application is subject to the Privacy Act of 1974, Pub. L. 93-579

A.  APPLICANT INFORMATION_______________________________________________________
    1. Name:__________________	_______________________________	___________________
Last				First				MI	Maiden Name (if any)

2.	Current Address:  ____________________________________	___________________
        Street Address						P.O. Box # (if any)	
___________________________	__________________	___________________
City						State				Zip Code

3.       Telephone Number: (____)____________________________

4.	Date of Birth:  ________________	5.  Social Security Number: ______________________

6.	Tribe: _____________________________________________	Roll Number: ____________

Reservation/Rancheria: _________________________________________________________

7.	Marital Status:  ____Married 	____Singled		____Widowed	____Other		

If you checked “Other”, please explain. ______________________________________________________________

8.       Are you Homeless? ____ No ____ Yes         9. Are you or spouse a Veteran?  ____ No  ____ Yes

Information About Spouse: __________________________________________________________

10.	Name:__________________	_________________	__	_______________________
Last				First				MI	Maiden Name (if any)

11.	Date of Birth:  ________________	12.  Social Security Number: _____________________

13.	Tribe: _____________________________________________	Roll Number: ____________

B. FAMILY INFORMATION___________________________________________________________

List all other persons living in household on a permanent basis.  Start with the oldest and provide Name, Date of Birth, Social Security Number, Relationship to Applicant, and Tribe/Roll Number .  
Name
Date of Birth
Social Security #
Relationship to Applicant
Tribe/Roll Number

























If you need more space, use a blank sheet of paper.
                                                                                                                            
BIA Form 6407	OMB Control No. 1076-0184 
ISSUED [ insert date]									          EXPIRATION DATE: [ insert date]

C.  INCOME INFORMATION_________________________________________________________

14.   Earned Income: Start with applicant, then list all permanent family members, including all who are listed under Parts A and B and have earned income.  Provide signed copy of SF-1040 (income tax return), W-2 forms, wage stubs, etc. for verification. 
Name
Annual Earned Income
Source of Income





















 
Total annual earned income: $ ____________________________

15.  Unearned Income: Start with applicant, then list all permanent family members, including all who are listed under Parts A and B and have unearned income such as social security, retirement, disability and unemployment benefits, child  support and alimony, royalties, per capita payments, interest, etc.  Provide check stubs, statements, individual Indian Money (IIM) ledgers, etc. for verification.  

Name
Annual Unearned Income
Source of Income






















      Total annual unearned income: $ ____________________________

16. TOTAL COMBINED ANNUAL HOUSEHOLD INCOME (earned + unearned): $ ___________________

D.  HOUSING INFORMATION________________________________________________________

17.

Location of the house to be repaired, renovated or constructed.  (Give address and detailed directions to this house).  **DRAW MAP ON BACK OF THIS PAGE**








18.

Provide a brief description of the problems you are experiencing with your house or the type of housing assistance for which you are applying.








19.
If repair assistance is needed, do you own _____ or rent _____ this house?

If renting, is the owner Indian?  ____No    ____ Yes

If yes, provide name of owner(s):
20.
Are you living in Overcrowded Conditions? ____ No  ____ Yes
21.
Is the condition of the home in a dilapidated state? ____ No  ____ Yes

BIA Form 6407	OMB Control No. 1076-0184 
ISSUED [Insert date]								                     EXPIRATION DATE: [Insert date]

HOUSING INFORMATION, continued.

22.
Is electricity available?  ____No  ____Yes  If yes, provide name of electric company: _______________.
23.
Type of Sewer system:
___ City Sewer
___ Septic Tank
___ Chemical Toilet
___ Outhouse



Water Source:	____ City Water	____ Private Well	____ Community Water Tank

____ Other (Please describe):
24.
No. of Bedrooms ____.

25.
House Size:  _____   (Square Feet)
[ LENGTH _____ ft/in]      [WIDTH _____  ft/in]

26.
Bathroom facilities in existing house:
Facility
Yes
No


Flush toilet




Bathtub




Sink/lavatory



E.  LAND INFORMATION____________________________________________________________

27.
Do you own the land on which you wish to renovate or build this home?  _____ Yes       _____ No

If no, can you provide proof that you can obtain land?  ____  Yes       _____ No

Provide the name of the owner(s):

28.


What is the current
status of the land?
___ Fee
___ Tribal Fee
___ Native/Restricted


___ Individual trust land
___ Tribal trust land
___ Public Domain


___ Individually restricted
___ Tribally restricted
___ Other:

29.
If you do not own the land, do you have: _____ Leasehold interest? ____ Use permit?                         ______ Indefinite assignment or joint ownership?  If so, please explain:


F.  GENERAL INFORMATION________________________________________________________



Yes
No
30.

Have you or anyone in your household ever received Housing Improvement Program assistance?



If yes, give amount received $_______; the year it was received: 19__ __; and the location of the house:


31.

Do you own any other house not occupied by your family?
If yes, state where the house is located: ____________ and who occupies it: __________.


32.
Do you live in a house built with Housing and Urban Development (HUD) funds?


33.
Is the HUD project still under operation of an Indian Housing Authority?


34.
Are you seeking Down Payment Assistance?



If yes, have you applied with USDA Rural Development or other lending institution?   Please provide a copy of the credit letter.


35.




If you are requesting assistance for a new housing unit, have you applied for assistance from:



	Indian Housing Authority?       If yes, provide date of application:____________



	Tribal Credit Program?            If yes, provide date of application:____________



	Other?  From who:___________    If yes, provide date of application:____________


36.

Does anyone in your family, who is a permanent resident listed under Parts A and B of this application, have a severe health problem, handicap or permanent disability?





If yes, provide name of family member __________________ and brief description of condition.  (Your servicing housing office will advise you if you must provide a statement of condition from one source, which may include a physician’s certification, Social Security or Veterans Affairs determination, or similar determination).


BIA Form 6407                                                                                      OMB Control No. 1076-0184 
ISSUED [Insert date]								               EXPIRATION DATE: [Insert date]

G.  APPLICANT CERTIFICATION ____________________________________________________
(Read this certification carefully before you sign and date your application.  Sign in ink).

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 material covered by the Privacy Act.  No record will be communicated to anyone or any agency unless requested in writing, by the applicant, or unless an officer or employee of the housing program or other Federal agency requires it in the performance of their duties.


Applicant’s Signature:  ___________________________________	Date:  ______________

Spouse’s Signature (if appropriate) _________________________	Date:  ______________



PRIVACY ACT STATEMENT

25 CFR 265 and 25 U.S.C. 13 authorize the collection of this information.  This information is covered by the system of record notice “Indian Housing Improvement Program, Interior, BIA-10.”  The primary use of this information is to determine eligibility for assistance under the Housing Improvement Program.  The records contained therein may only be disclosed in accordance with the routine uses and may not otherwise be disclosed by any means of communication to any person, or to another agency, except pursuant to a written request by, or with prior written consent of the individual to whom the record pertains.  If the BIA uses the information furnished on this form for purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes.  Executive Order 9397 authorizes the collection of your Social Security number.  Furnishing the information is voluntary but failure to do so may result in disapproval of your application.  

PAPERWORK REDUCTION ACT STATEMENT

This information is being collected to select eligible families or individuals to participate in the Housing Improvement Program.  Response to this request is required to obtain a benefit in accordance with 25 CFR 256.  You are not required to respond to this collection of information unless it displays a currently valid OMB control number.  This information will be used to determine the eligibility and the ranking of the applicant.  Public reporting burden for this form is estimated to average 1 hour 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 Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.