DARKO AFFORDABLE HOUSING SOLUTIONS, LLC 125 E Broadway, P.O. BOX 1161 ANADARKO, OK Phone: FAX:

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1 DARKO AFFORDABLE HOUSING SOLUTIONS, LLC 125 E Broadway, P.O. BOX 1161 ANADARKO, OK Phone: FAX: STORM SHELTER ASSISTANCE PROGRAM APPLICATION The DAHS Storm Shelter Assistance Program is to assist low income Native American families acquire a storm shelter. This program is a one-time offering based upon the availability of units. Applicants are also subject to the Storm Shelter Program Policies, guidelines, submittal deadlines, and service area requirements. See program policy for details. INSTRUCTIONS: Please read carefully. Only completed applications with all required documentation will be accepted. Incomplete applications will not be processed. 1. Verification of Tribal enrollment with a federally recognized tribe for Head of Household OR Spouse: CDIB,OR Tribal ID OR official correspondence from the Tribal enrollment office or Bureau of Indian Affairs. 2. Social Security Cards for all family members 3. Identification : State Driver s License, OR State ID Card, OR Birth Certificate, OR Tribal ID OR CDIB. Name changes may be documented by birth certificates, marriage certificates or divorce decrees. 4. DAHS Income verification is required for everyone 18 yrs. of age or older. Third party verification is preferred. Check stubs, OR payment statements. Prior year tax returns may be submitted. Transaction report from BIA for last 12 months if you own Trust Property. 5. Copy of marriage license, OR marriage certification statement, and/or proof of custody (if applicable). 6. Property Deed or Certified Title Status Report (TSR) from the BIA is required for privately owned property.* * The property must be owned by the applicant, Kiowa Tribe, Kiowa Housing Authority, Kiowa Tribal Housing Program or Kiowa Housing Services. Property owned by another party or relative is not acceptable unless a legal lifetime use agreement is in place and has been recorded with the appropriate jurisdictional authority. The property on which the storm shelter is to be installed must be the principal residence of the applicant. Final installation is subject to local building codes.

2 Date: Applicant Name: Mailing Address: City: State: Zip: Daytime Phone: Alternate phone Finding Directions: City: State: Zip: 1. Are you or your spouse an enrolled member of the Kiowa Tribe? YES NO 2. Do you owe a debt to the Kiowa Tribe or other Kiowa Tribal housing entity? YES NO If YES, List which entity: 3. Are you living in a Kiowa Tribe or other Kiowa Tribal housing entity home? YES NO If YES, List entity: 4. Are you or your spouse a veteran or active military? YES NO 5. OPTIONAL INFORMATION: In order for DAHS to comply with Uniform Accessibility, Sec. 504, are you, your spouse or any other member of your family considered disabled? YES NO If YES, describe the disability: 6. Are all household members U.S. citizens? YES NO If NO, please explain and provide U.S. Immigration Service Form (aka Green Card): 7. Have you ever received housing assistance from any Tribal housing agency, HUD NAHASDA, housing authority or Tribe? YES NO If YES, please describe assistance received and approximate year served:

3 8. Do you have an existing storm shelter? YES NO If YES, please describe the purpose/reason for your application: 9. Give name of any full-time students 18 yrs of age or over and submit documentation: 10. Household Composition, Persons who live in your home (include yourself) Name(s) of Your Family Members Relationship To You Self/Hd of Hshld Date of Birth *Social Security number is required for all family members who are 6 years of age or older. (M or F) Social Security Number* 11. Family Income Verification (List income for each person living in your home 18 yrs of age or over.) a. Income from employment Mbr # Employer Name(s) & Address Rate Per Hour 1. $ Rate Per Week Total Per Year 2. $ 3. $

4 b. Other Income: Other sources of income include alimony, relief, service allotments, assistance from relatives, payments for foster children, and any other regular source of income. Please do not list income that cannot be anticipated with certainty. Source Rate Per Month Total Per Year TANF $ Social Security $ S.S.I. $ Unemployment $ Pensions $ Leases $ Own Business $ Other* $ c. Assets such as your home cash, savings account, trust account, rental property, securities, stocks etc., and retirement, pensions, inheritances, personal investment property, guardian/power of attorney income and any other income: Source Value Total Per Year Pensions $ Leases $ Own Business $ Home $ Other* $ 12. Disclosure Statement of Applicant: Please identify any of your immediate family members (or self) that currently serve in any of these capacities for the Kiowa Tribe: Tribal Chairman; Tribal Council; Housing Board; Tribal Employee; or DAHS employees. An immediate family member includes: father; mother; son; daughter; husband; wife; spouse/partner; brother; sister. This disclosure applies to all household members listed on your application. Check answer below. YES, I have NO, I do not have an immediate family member (or self) that serves the Kiowa Tribe in one of the positions listed above. If YES, Give name and title of your immediate family member (or self) and his/her relation to you or your household member:

5 14. Signature and Consent To Release Information: I understand that this application is not a contract and is not binding in any manner. I hereby authorize Darko Affordable Housing Solutions to obtain any and all information necessary for the purpose of verifying the statements made above. I also understand that it is my responsibility to inform Darko Affordable Housing Solutions if there is any change in my family status along with reporting any changes in income, living conditions and change of address. I hereby certify that all information contained herein is accurate to the best of my knowledge and I understand that knowingly providing false information is punishable by fine and imprisonment. Date Signature ELIGIBILITY DETERMINATION (DAHS Use Only) Date and time COMPLETED application received by DAHS: Signature and Title of DAHS employee receiving COMPLETED application: Based upon the completed application and supporting documentation submitted, and the DAHS Rental Hsg Policy, the applicant is determined to be: Eligible Not Eligible: If not eligible, state reason: Signature, title and date for person certifying eligibility:

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