DARKO AFFORDABLE HOUSING SOLUTIONS, LLC 125 E Broadway, P.O. Box 1161 Anadarko, OK Phone Fax HOME REHAB

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1 DARKO AFFORDABLE HOUSING SOLUTIONS, LLC 125 E Broadway, P.O. Box 1161 Anadarko, OK Phone Fax HOME REHAB PROGRAM DESCRIPTIONS: DAHS Home Rehab Program is to assist the primary residence of homeowners by making necessary improvements, repairs, modernization, rehabilitation, uniform accessibility modifications, and addressing certain maintenance items. Joint ownership with other non-applicants is not acceptable, unless proper documentation concerning the lifetime or exclusive use of the property by the applicant can be obtained. Home Rehab (Minor) is limited to assistance once every five years. Home Rehab (Major) program, assistance is limited to a one-time offering. Applicants must have homeowners insurance. GENERAL INSTRUCTIONS: Please read carefully and submit a completed application with all required documentation. INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED. If a question does not apply to you, answer with N/A, 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). Property Deed or Certified Title Status Report (TSR) from the BIA is required for privately owned property.* 6. Proof of utilities. 7. If applicable, proof of disability. * The property must be owned by the applicant. 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 which receives services must be the principal residence of the applicant.

2 APPLICATION FOR HOUSING REHAB A. PRE-APPLICATION SCREENING: 1. Are you living in a Kiowa or other Indian/Tribal housing authority/entity home? YES NO If YES, List Entity, address & phone: 2. Do you owe a debt to the Kiowa or other Indian/Tribal housing authority/entity? YES NO If YES, Give details: 3. Have you received any prior housing assistance or similar assistance (since 1998 or later) for which you are applying for from any other HUD/NAHASDA program, housing authority, or tribal entity? YES NO If YES, when and what assistance and entity/agency? a. Do you currently own your residence? YES NO If YES, attach proof of ownership (deed/title/tsr). What is the estimated value of your residence? $ Do you currently own any other property? b. If YES, what is the value of this property? $. Please provide a copy of any income derived from this property 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 household considered disabled? YES NO If YES, describe the disability and attach documentation: 6. Are all household members U.S. citizens? YES NO If NO, give name and provide U.S. Immigration Service Form (aka Green Card). 7. 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 YES, I have 12/29/15 Page 2 of 5

3 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: B. GENERAL APPLICANT INFORMATION: 1. Applicant Name, Head of Household: DOB: a. Social Security #: & Tribal Affiliation: b. Mailing Address: Apt.#: c. Daytime Phone: Alt. Phone/ d. Applicant Status (Circle): Single Married Separated Divorced Widow(er) Veteran e. Are you or your spouse active military or an honorably discharged veteran? YES NO If YES, give name & provide documentation: C. HOUSEHOLD COMPOSITION: Excluding Applicant, list all other persons living in your home, include name, social security #, tribal affiliation, relationship (son, daughter & etc.), date of birth & gender. # Name & Social Security # Tribe Relationship DOB & M or F /29/15 Page 3 of 5

4 D. HOUSEHOLD INCOME: List income or other assets available for each person living in your home. Income includes wages, social security, SSD, VA, annuity, Dept. of Human Services, pensions, retirement, alimony, and child support, etc. and other assets includes cash, trust account, rental property, securities, stocks, inheritances, personal investment property, guardian/power of attorney income or any other income. # Name 1 Type of Income or Asset Mtly / Total Amt Give name of any full-time students 18 yrs of age or over and submit documentation: E. APPLICANT S REQUESTED PROGRAM ASSISTANCE: NOTE: Listed programs are one-time assistance extending to head of household and spouse. Ineligibility includes, but not limited to, debt to DAHS, Kiowa Tribe, public or Indian Housing Authority or tribally designated housing entity. In addition, there may be exclusions and/or restrictions on homes built prior to 1978 and exclusion of lease/rent to own housing units or re-financing. Review specific program policies for clarification and complete the applicable sections under Home Rehab. a. Unit Finding Address (include County Rd and St. number and/or name): b. Yr. Home Built: Number of Bedrooms: c. Provide proof of ownership (deed/title/tsr) and occupancy of the home/unit as the primary residence (utility bills). DAHS reserves the right to determine adequate documentation. d. Indicate which Home Rehab Program you are applying for: Major? OR Minor? e. Do you have homeowner insurance? YES NO If YES, please provide a copy of the declarations page. 12/29/15 Page 4 of 5

5 APPLICANT CERTIFICATION I/We certify, to the best of my/our knowledge, that the information and statements given to Darko Affordable Housing Solutions, LLC herein, is accurate, true and complete. I/We understand that false statements or misrepresentation of information is punishable under federal law and that any such false statements are grounds for termination/ineligibility for housing assistance. I/We also understand that I/We will be placed on a waiting list for the applicable program for which I/We are applying for upon submittal of all requested documentation. Warning: Section 1001 of Title 18 of the U.S. Code makes it a criminal offense to make willful, false statements or misrepresentations of any material fact involving the use or obtaining of federal funds. Applicant: Date: Co Applicant: Date: RECEIPT OF COMPLETED APPLICATION & 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 DAHS Program Policy, the applicant is determined to be: Eligible Not Eligible for Program: If not eligible, state reason: Signature, title & date for person certifying eligibility: 12/29/15 Page 5 of 5