Part 3: Lower Brule Housing Authority Application Prospective Lessee Name * First Name Last Name Address * Phone Number (###) ### #### Program * Rental Housing Program Home Ownership Program A. Family Composition * A. Persons Who Will Move into the House. Please list the following information for EACH person who will move into the house. 1. Name 2. Relation to Family Head 3. Date of Birth 4. Age 5. Sex 6. Occupation and/or School Grade 7. Social Security Number B. Family Composition * B. Do you anticipate any changes in your family composition? C. Family Composition * Are you or any other member of your household disabled? Veteran? Handicapped? D. Family Composition * Have you or any member of your household ever lived in one of our units before? If yes, what unit number: Family Income * Please list the following information below for each household member: Income from employment: 1. Family Member 2. Hours per week 3. Rate per hour 4. Rate per month 5. Rate per year 6. Employer Name and Address A. Present Housing Condition and Need: * Without Housing? Yes or No. Reason? Present Living Arrangements. * Present/Previous Landlord Address or Utility Company and Address or Credit Reference and Address If this section is not filled out completely, your application will not be considered for eligibility. B. About to be without housing? Yes or No. * Please list type of Notice and Effective Date. Do you have? * Drinkable Running Water in the Dwelling Unit? Working Toilet in the Dwelling Unit? Installed Usable Tub/Shower in the Dwelling Unit? Operating Sink an Proper Stove Connections in the kitchen? Adequate Electric Wiring System in the Dwelling Unit? Adequate and Safe Heating facilities in the Dwelling Unit? D. How many bedrooms does your present dwelling unit have? How many persons now reside in the dwelling unit? * E. Is your present dwelling structurally safe? Yes or No? * F. How many families reside in the dwelling unit? * G. What is your monthly rent? * Assets * A. Does anyone in the household own a car, truck, motorcycle, boat, recreational vehicle (camper, snowmobile), or any other vehicle? Yes or No. Please list Type and Estimated Value $ Disclosure * Please list any close relatives working for the LB Housing Authority or relation to seated members of the Board of Commissioners or Tribal Council. Applicant Signature * I understand that this is not a contract and does not bind either party. The above information is true and complete to the best of my knowledge. I have no objection to inquiries being made for the purpose of verifying the statements made herein. Date * MM DD YYYY Thank you!