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Apply for a NAHASDA-Assisted Rental or the Rental Assistance ProgramChristopher2022-02-04T00:48:55-09:00

NAHASDA-Assisted Rent and Rental Assistance Application Form

Notice to applicants: Kodiak Island Housing Authority (KIHA) is an Indian Housing Authority. In October 1996 Congress passed a law entitled the Native American Housing Assistance and Self Determination Act(NAHASDA) of 1996. Under this law, KIHA is required to give preference in its HUD-funded programs to Native American households. Only American Indian and Alaska Native applicants are eligible for KIHA's Rental Assistance Program (RAP).

1Applicant Info
2Co-Applicant Info
3Household Member Info
4Rental History
5Income & Assets
6Employment Info
7References
8Additional Info
9Consent Forms

Applicant Information (Head of Household)

Are you applying for an affordable rental unit or to receive rental assistance?(Required)
If accepted to the NAHASDA-Assisted Rental Program, you will be a tenant at a KIHA-owned rental property. In the Rental Assistance Program, you choose your own rental and KIHA provides assistance with rent payments.
Which properties are you interested in?(Required)
What size unit are you requesting?(Required)
Are you requesting a unit with handicap accessibility features?
Full Legal Name(Required)
Format xxx-xx-xxxx
Sex(Required)
MM slash DD slash YYYY
Are you a U.S. Citizen?(Required)
Are you Native American?(Required)

The Rental Assistance Program is only for Alaska Native and American Indian (AI/AN) applicants. If you are not AI/AN, you are ineligible for this program.

Please call our Housing Department at (907) 486-8111 to ask about other program options.

Is your spouse the co-applicant?(Required)
Would you like to include a co-applicant on this application?(Required)
A co-applicant may be a significant other or partner with whom you share all household responsibilities.
Current Mailing Address(Required)
Current Physical Residence Address
If different from current mailing address.
If different from daytime phone.
If different from daytime phone.
MM slash DD slash YYYY
Employer's Mailing Address(Required)
Will anyone else live in the home with you?(Required)

Co-Applicant Information

Full Legal Name(Required)
Sex(Required)
MM slash DD slash YYYY
Are you a U.S. Citizen?(Required)
Are you a Native American?(Required)
Current Mailing Address(Required)
Current Physical Residence Address
If different from mailing address.
If different from daytime phone number.
If different from daytime phone number.
Are you currently employed?(Required)
MM slash DD slash YYYY
Employer's Mailing Address(Required)

Other Household Members

Will anyone aside from yourself (and the co-applicant, if applicable) be living in the household?(Required)
Full Legal Name(Required)
MM slash DD slash YYYY
Sex(Required)
Format xxx-xx-xxxx
Do you have more household members to add?(Required)
Full Legal Name(Required)
MM slash DD slash YYYY
Sex(Required)
Format xxx-xx-xxxx
Do you have more household members to add?(Required)
Full Legal Name(Required)
MM slash DD slash YYYY
Sex(Required)
Format xxx-xx-xxxx
Do you have more household members to add?(Required)
Full Legal Name(Required)
MM slash DD slash YYYY
Sex(Required)
Format xxx-xx-xxxx
If you have more household members to include on this application, please upload a list including each one's name, birthdate, sex, SSN, and relationship to the applicant here.
Accepted file types: jpg, gif, pdf, Max. file size: 50 MB.

Previous Addresses and Landlords

Begin with the most recent and go back for three years.
Prior Residence Address(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Did you own or rent this property?(Required)
Do you have another residence to add?(Required)
Address of Property(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Did you own or rent this property?(Required)
Do you have another residence to add?(Required)
Address of Property(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Did you own or rent this property?(Required)
If you have additional properties to include on this application, please upload a list with the property address, dates of occupancy, whether you rented or owned the property, the name and phone number of the landlord or mortgage servicer, and your name used while living their for each property.
Accepted file types: jpg, gif, pdf, Max. file size: 50 MB.

Household Income

Please indicate the gross monthly household income for ALL adult wage earners. Use the amount earned before taxes and other withholdings.
Total amount before taxes and other withholdings.
Wages, child support, public assistance, etc.
Total amount before taxes and other withholdings.
Wages, child support, public assistance, etc.
Total amount before taxes and other withholdings.
Wages, child support, public assistance, etc.
Describe and provide detail for all other income, such as Alaska Permanent Fund Dividends, insurance settlements, unemployment compensation, worker's compensation, pension or retirement, etc.

Household Bank Accounts

Please list the bank and credit union accounts that belong to the adult household members. Upload additional written information if necessary.
Type of Account(Required)
Type of Acount
Type of Account
If you have more bank account information to add, please upload a written list.
Accepted file types: jpg, gif, pdf, png, Max. file size: 50 MB.

Employment Information

Please provide the following information regarding previous jobs you have had in the past 24 months. Include information for all adults in your household. If you were self-employed or unemployed during this time, please indicate this.
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
If the adult members of your household had more than four employers over the last 24 months, please upload written information about all additional employers. Include self-employment and periods of unemployment.
Accepted file types: jpg, gif, png, pdf, heic, Max. file size: 50 MB.

Personal References

Provide the names and contact information for three people (not related to you) who can provide a personal reference for you.
Name(Required)
Address(Required)
Name(Required)
Address(Required)
Name(Required)
Address(Required)

Additional Questions

Please answer the following questions and provide detail as needed. If you need to provide an explanation for any of the answers, please upload written information. Providing false or incomplete information may be considered fraud and carries serious consequences that can include fines or imprisonment.
Do any members of your household receive native dividends?(Required)
How often do you receive disbursements?(Required)
Enter the amount of each disbursement, not the total of all disbursements.
Have you or a member of your household ever been arrested, charged, or convicted of any crime other than a traffic violation?(Required)
Have you or a member of your household every been evicted or had a lease terminated?(Required)
Have you or a member of your household ever participated in a federally subsidized housing program?(Required)
Address of Housing Authority(Required)
MM slash DD slash YYYY
MM slash DD slash YYYY
Do you or a member of your household owe money to a current or past landlord, including any other housing agency or housing authority?(Required)
Does anyone in your household have a disability that requires a unit with handicap accessibility features?(Required)
(i.e. wheelchair accessible unit, fire alarms for the hearing impaired, grab bars, etc.)
If you are age 62 or over and are disabled or handicapped, do you have medical expenses that are NOT reimbursed by medical insurance or other programs?(Required)
KIHA maybe be able to factor in these costs when calculating your rental assistance. Briefly describe expenses & attach proof by uploading supporting documents below.
Drop files here or
Accepted file types: pdf, jpg, gif, png, heic, Max. file size: 50 MB, Max. files: 5.
    If you have children under age 13, do you pay for childcare in order to work or attend school?(Required)
    Drop files here or
    Max. file size: 50 MB, Max. files: 3.
      Have you or a member of your household sold, transferred, or given away any asset in the past 24 months?(Required)
      Assets can include but are not limited to real estate, automobiles, bank accounts, cash, stock, etc.
      Please explain what was sold, transferred, or given away and when the transaction occurred.
      Does any household member require the presence of an assistance animal?(Required)
      Drop files here or
      Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB, Max. files: 3.
        Does anyone in the household request a reasonable accommodation or modification?(Required)
        Do you have a relationship with any Kodiak Island Housing Authority employee?(Required)

        Consent & Authorization

        Applicant Consent(Required)
        I certify that the information I have provided to Kodiak Island Housing Authority in this application is true and correct. I understand that my current and former employers, landlords, and references will be contacted.

        I authorize Kodiak Island Housing Authority to obtain a credit report or other form of verification regarding the information I have provided.

        I consent to and authorize Kodiak Island Housing Authority to verify any and all information provided here. I agree that Kodiak Island Housing Authority may terminate any agreement with me, including an application and/or a lease agreement, if I have made a false statement or am aware of a false statement in this application.

        I authorize a photocopy of my signature or digital entries below to be used and accepted as though they were original signatures.
        MM slash DD slash YYYY
        Co-Applicant Consent(Required)
        MM slash DD slash YYYY
        Kodiak Island Housing Authority does not discriminate against any person because of race, color, religion, sex, disability, familial status or national origin. We do business in accordance with the Federal Fair Housing Law. If you believe you have been discriminated against you may contact the Fair Housing and Equal Opportunity toll-free hotline at 1-(800) 669-9777 {TTY users: 1-(800) 927-9275}, or via the internet at www.hud.gov.
        Privacy Policy(Required)
        KIHA collects non-public personal information about you from the following sources:

        * Information KIHA receives from you on applications or other forms;
        * Information about your transactions with KIHA or others; and
        * Information KIHA receives from others, such as a consumer reporting agency, court
        records, employers.

        KIHA does not disclose non-public personal information about you to anyone, except as
        authorized by you or permitted by law.

        If you decide to close your account(s) or become an inactive client, KIHA will adhere to the privacy policies and practices as described in this notice. To maintain security of client information, KIHA restricts access to your personal and account information to those employees who need to know that information to provide you with our products and/or services.

        KIHA maintains physical, electronic and procedural safeguards that comply with federal standards to guard your non-public personal information. Your confidence in KIHA is important and we want you to know that your personal and account information is safe. If you have any questions or concerns, please contact us at:

        Kodiak Island Housing Authority
        3137 Mill Bay Road
        Kodiak, Ak. 99615
        Telephone: (907) 486-8111 or Toll free: 1-(800) 478-5442
        Website: www.kodiakislandhousing.org
        MM slash DD slash YYYY
        Privacy Policy (Co-Applicant)(Required)
        MM slash DD slash YYYY
        Authorization for Release of Information(Required)
        I authorize and direct any federal, state, or local agency and any organization, business, or individual to release to Kodiak Island Housing Authority (KIHA) any information or materials needed to complete and verify my
        application for, or participate in, any KIHA assisted housing program. Verifications and inquiries that may be requested include, but are not limited to:

        * IDENTITY AND MARITAL STATUS
        * INCOME FROM ANY SOURCE
        * CREDIT HISTORY
        * ASSETS OF ANY KIND, INCLUDING ASSETS DISPOSED OF IN THE LAST TWO (2) YEARS
        * POLICE RECORDS AND CRIMINAL HISTORY
        * EMPLOYMENT INCOME
        * RESIDENCES AND RENTAL ACTIVITY
        * MEDICAL & CHILD CARE PROVIDERS

        Agencies or individuals that KIHA may contact include:
        * PAST AND PRESENT LANDLORDS
        * PAST AND PRESENT EMPLOYERS
        * COURTS AND POST OFFICES
        * DEPT. OF HEALTH & SOCIAL SERVICES
        * SCHOOLS AND COLLEGES
        * DEPT. OF LABOR
        * LAW ENFORCEMENT AGENCIES
        * INTERNAL REVENUE SERVICE
        * UTILITY COMPANIES
        * DEPT. OF EDUCATION
        * VETERANS ADMINISTRATION
        * PUBLIC RECORDS
        * FINANCIAL INSTITUTIONS
        * SOCIAL SECURITY ADMINISTRATION
        * AK PERMANENT FUND CORPORATION
        * MEDICAL AND CHILD CARE PROVIDERS
        * PRIVATE SOCIAL SERVICE AGENCIES
        * PENSION OR RETIREMENT SYSTEMS
        * PERSONAL REFERENCE
        * PAYEES OR TRUSTEES
        MM slash DD slash YYYY
        Authorization for Release of Information (Co-Applicant)
        MM slash DD slash YYYY

        Declaration of Citizen or Non-Citizen Status

        In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the U.S. Please read this Declaration Statement carefully. Feel free to consult with an immigration lawyer or other immigration expert of your choosing before signing.
        Certification(Required)
        I certify under penalty of perjury that, to the best of my knowledge, I am lawfully within the United States because:
        For non-citizens who are 62 years of age or older or who will be 62 years of age or older AND receiving assistance under a Section 214 covered program on June 19, 1995. If you are eligible and elect to select this category, you must include a document providing evidence of proof of age. No further documentation of eligible immigration status is required.
        Accepted file types: jpg, pdf, png, gif, Max. file size: 50 MB.
        Type of Immigration Status(Required)
        See the description below for help determining which of these options apply to you.
        Immigration status under §§101(a)(15) or 101(a)(20) of INA - A non-citizen lawfully admitted for permanent residence, as defined by §101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by §101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category includes a non-citizen under §§210 or 210A or the INA (8 U.S.C. 1160 or 1161), [special agricultural worker status], who has been granted lawful temporary resident status.

        Permanent residence under §249 of INA - A non-citizen who entered the U.S. before January 1, 1972, or such later date as enacted by law, and had continuously maintained residence in the U.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under §249 of the INA (8 U.S.C 1259) [amnesty granted under INA 249].

        Refugee, asylum, or conditional entry status under §§207, 208 or 203 of INA - A non-citizen who is lawfully present in the U.S. pursuant to an admission under §207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under §208 of the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under §203(a)(7) of the INA (U.S.C. 1153(a)(7)) before April 1, 1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic national calamity [conditional entry status].

        Parole status under §212(d)(5) of INA - A non-citizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under §212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status].

        Threat to life or freedom under §243(h) of INA - A non-citizen who is lawfully present in the U.S. as a result of the Attorney General's withholding deportation under §243(h) of the INA (8 U.S.C. 1253(h)) [threat to life or freedom].

        Amnesty under §245A of INA - A non-citizen lawfully admitted for temporary or permanent residence under §245A of the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A].
        Untitled

        3137 Mill Bay Rd.

        Kodiak, Alaska 99615

        (907) 486-8111

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        AK Business License: 310841

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