HOUSING IMPROVEMENT PROGRAM ADDENDUM to BIA FORM 6407

OMB Control No. 1076-184

Expiration date: XX-XXXX

Expiration Date xx-xx

HOUSING IMPROVEMENT PROGRAM

ADDENDUM to BIA FORM 6407

FISCAL YEAR:

2019

Applicant Name:		Date of Prior Application:
Spouse Name:		Agency/Chapter:

I (We) hereby request that the HIP/BIA Form 6407 housing application be carried forward, for one year, into the next program year to be considered for housing assistance. I (We) understand I (we) must disclose and report all changes in my (our) household size, total annual household income, and/or living situations. I (We) hereby attest to the following:

No, there are no changes in the household size.

Yes, there are changes in the household size as stated herein:

Increase in number of household members Decrease in number of household members

Name(s)	Date of Birth	Relationship to Applicant	Tribe/Census No.

No, there are no changes in the total annual household income.

Yes, there are changes in the total annual household income as stated herein:

Increase amount in total household income Decrease amount in total household income

You must provide current income documentation of Federal Income Tax return, SSB, SSI, VA Award Letters, etc.

Name of Recipient	Source of Income	Amount

Explain of Any Other Change(s): _______________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________

I (We) certify that all the answers given are true; complete and correct to the best of my (our) 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 housing assistance, and the false or misleading statements may constitute a violation of 18 U.S.C., 1001.

Applicant’s Signature:		Date:
Spouse’s Signature:		Date:
Form Reviewed by:		Date:

Eligibility Technician

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.

Date of this Addendum: ______________