Student Rental Assistance Program Application

Complete all sections, or indicate N/A if it doesn't apply. Contact KIHA's Housing Department if you have questions about the form or associated paperwork.

1Applicant Information

2School Information

3Sources of Financial Aid

4Housing Costs During the School Year

5Household Composition

6Household Income

7Assets

8Additional Information

9Notices and Disclosure Statements

Full legal name(Required)

First Last

Sex

Male

Female

Social Security Number(Required)

Format xxx-xx-xxxx

Date of Birth(Required)

Are you a U.S. Citizen?(Required)

Yes

Are you a Native American(Required)

Yes

Marital Status(Required)

Married

Not married

Married and not living with spouse

The Student Rental Assistance Program is for Alaska Native/American Indian applicants only. Please contact KIHA's Housing Department to inquire about housing programs for non-AIAN applicants.

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Physical Address

If different from mailing address.

Street Address Address Line 2 City State ZIP Code

Cell Phone(Required)

Home Phone

Work Phone

Email(Required)

Name of current employer

Employer's phone number

Current landlord's name(Required)

First Last

Current landlord's phone(Required)

Name of your nearest living relative(Required)

First Last

List any other names you have used in the past 10 years, including nicknames.

Start Date(Required)

Anticipated or actual start date of the school you will attend.

End Date(Required)

Anticipated end date of the school you will attend.

Full name of school(Required)

Mailing address of the school(Required)

Street Address Address Line 2 City State ZIP Code

Physical address of the school(Required)

Street Address Address Line 2 City State ZIP Code

Phone number of the school(Required)

Fax number of the school(Required)

List ALL grants, scholarships, loans, gifts, or other financial aid you (the student) have received or will receive for this school year. Upload evidence of this assistance if available.

Type of aid(Required)

Example: grant, scholarship, gift, loan, etc.

Name of aid source(Required)

First Last

Phone of aid source(Required)

Amount(Required)

Type of aid

Example: grant, scholarship, gift, loan, etc.

Name of aid source

First Last

Phone of aid source

Amount

Type of aid

Example: grant, scholarship, gift, loan, etc.

Name of aid source

First Last

Phone of aid source

Amount

Additional Information and supporting documents(Required)

If you have additional sources of financial aid, upload a written statement. Upload evidence of all financial aid listed. If you are not able to upload supporting documents, you may email them or drop them off at one of our office locations.

Drop files here or

Accepted file types: jpg, pdf, gif, heic, Max. file size: 50 MB, Max. files: 5.

Type of Expense(Required)

Example: rent, shared rent, electric, heat, telephone, food, etc.

Paid to (name)(Required)

Paid to (phone)(Required)

Monthly cost(Required)

Type of Expense

Example: rent, shared rent, electric, heat, telephone, food, etc.

Paid to (name)

Paid to (phone)

Monthly cost

Type of Expense

Example: rent, shared rent, electric, heat, telephone, food, etc.

Paid to (name)

Paid to (phone)

Monthly cost

Additional Information & Supporting Documents(Required)

If you have more anticipated monthly housing expenses, upload a written statement. Upload evidence of all monthly housing costs reported. If you are not able to upload supporting documents, you may email them or drop them off at one of our office locations.

Drop files here or

Accepted file types: jpg, pdf, heic, gif, Max. file size: 50 MB, Max. files: 5.

List everyone who lives in your home, starting with yourself. If you are living with your parents or another adult family member, you must list them too. Upload additional written information if necessary.

Name(Required)

First Last

Date of Birth(Required)

Applicant's date of birth

Sex(Required)

Male

Female

Social Security Number(Required)

Format xxx-xx-xxxx

Relationship to applicant(Required)

Name

First Last

Date of Birth

Sex

Male

Female

Social Security Number

Format xxx-xx-xxxx

Relationship to applicant

Example: mother, father, daughter, son, mother-in-law, cousin, etc.

Name

First Last

Date of Birth

Sex

Male

Female

Social Security Number

Format xxx-xx-xxxx

Relationship to applicant

Example: mother, father, daughter, son, mother-in-law, cousin, etc.

Name

First Last

Date of Birth

Sex

Male

Female

Social Security Number

Format xxx-xx-xxxx

Relationship to applicant

Example: mother, father, daughter, son, mother-in-law, cousin, etc.

Additional household members

Upload written information for any additional household members not included in the form fields above.

Accepted file types: jpg, heic, pdf, gif, Max. file size: 50 MB.

Type of asset(Required)
Account number or number of shares
Leave blank if listing real property, a car, etc.
Asset owner(Required)
First Last
Estimated value or current account balance(Required)
Description or location of the asset(Required)
Name of native corporation, make and model of vehicle, bank where account is located, etc.

Type of asset
Account number or number of shares
Leave blank if listing real property, a car, etc.
Asset owner
First Last
Estimated value or current account balance
Description or location of the asset
Name of native corporation, make and model of vehicle, bank where account is located, etc.

Type of asset
Account number or number of shares
Leave blank if listing real property, a car, etc.
Asset owner
First Last
Estimated value or current account balance
Description or location of the asset
Name of native corporation, make and model of vehicle, bank where account is located, etc.

Additional assets
Upload a written statement listing any assets not included in the form fields above. Include the type of asset, account number or number of shares, asset owner, estimated value, and location of the asset for each asset listed.
Accepted file types: jpg, gif, pdf, heic, Max. file size: 50 MB.

Please answer all of the following questions and provide detail as necessary. False or incomplete information may be considered fraud and carries serious consequences that can include fines or imprisonment.
Have you or a member of your household ever been arrested, charged or convicted of any crime other than a traffic violation?(Required)

Yes

No
Please state who, list the date, and state the type or arrest and/or conviction.(Required)
Have you or a member of your household ever been evicted or had a lease terminated?(Required)

Yes

No
Please explain when and why.(Required)
Have you or a member of your household every participated in a federally subsidized housing program?(Required)

Yes

No
Start date(Required)
MM slash DD slash YYYY

End date(Required)
MM slash DD slash YYYY

Name of housing authority(Required)

Address of housing authority(Required)
Street Address Address Line 2 City State ZIP Code

Do you or a member of your household owe money to a current or a past landlord, including any other housing agency or housing authhority?(Required)

Yes

No
Please explain to whom you/they owe and why.(Required)
If you are age 62 or over, are disabled or handicapped, do you have medical expenses that are NOT reimbursed by insurance or other programs?(Required)

Yes

No

N/A
KIHA may be able to factor these costs in when calculating your payment. Briefly describe the expenses and attach proof using the form field at the end of this section.(Required)
If you have children under age 13, do you pay for childcare in order to work or attend school?(Required)

Yes

No

N/A
KIHA may be able to factor these costs in when calculating your payment. Provide the name and phone number of your childcare provider and briefly describe the expenses. Attach proof using the upload form field at the end of this section.(Required)
Have you or any other member of your household sold, transferred, or given away any asset(s) in the past 24 months?(Required)
Assets can include but are not limited to real estate, automobiles, bank accounts, cash, stock, etc.

Yes

No
Please explain what was sold, when, and for what price. If the asset was given away, state the type of asset, to whom it was given, and its value at the time.(Required)
Additional information and/or supporting documents
Max. file size: 50 MB.

Our Privacy Policy

We collect non-public personal information about you from the following sources:

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

We do 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, we will adhere to the privacy policies and practices as described in this notice.

To maintain security of client information, we restrict 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. We maintain physical, electronic and procedural safeguards that comply with federal standards to guard your non-public personal information.

Your confidence in us 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:

Kodiak Island Housing Authority
3137 Mill Bay Road Kodiak, AK 99615
Telephone: (907) 486-8111 or Toll free: 1-(800) 478-5442 Fax: (907) 486-4432 or (907) 486-8723
Website: www.kodiakislandhousing.org

Privacy Act Notice

This information is to be used by Kodiak Island Housing Authority (KIHA) in determining whether you qualify for its program(s), the recommended unit size, and the amount the participant must pay toward rent and utilities. It will not be disclosed outside KIHA except as required and permitted by law. You do not have to provide this information, but if you do not your application for approval or continuance may be delayed or rejected. The information used in this form is authorized by Title 38, USC, Chapter 37 (if VA), by 12 USC, Section 1701 et. seq. (if HUD/FHA); by 42 USC, Section 1452b (if HUD/CPD); and Title 42 USC, 1471 et. seq., or 7 USC, 1921 et. seq (if USDA).

Equal Opportunity Notice

Kodiak Island Housing Authority does not discriminate against any person because of race, color, religion, sex, handicap, familial status or national origin. We do business in accordance with the Federal Fair Housing Law.

Notice Regarding Fair Housing

If you believe you have been discriminated against you may contact the Fair Housing & Equal Opportunity Hot Line toll-free at 1-(800) 877-0246 or (206) 220-5170 or TTY (206) 220-5185, or write to: US Dept. of Housing & Urban Development Building 909 First Avenue, Room 205 Seattle, Wa. 98104-1000
Certification & Authorization(Required)
I certify that the information I have provided to the Kodiak Island Housing Authority is accurate and complete to the best of my knowledge and belief. I understand that providing false statements or information is punishable under Federal Law. I also understand that providing false statements or information is grounds for termination of housing assistance and termination of occupancy. I hereby authorize Kodiak Island Housing Authority to verify information regarding my current or prior income, government benefits and assets, and authorize a photocopy of my name as entered below to be used and accepted as if it were an original signature.
Printed name as signature(Required)

Date signed(Required)
MM slash DD slash YYYY

Student Rental Assistance Program Application

The Student Rental Assistance Program is for Alaska Native/American Indian applicants only. Please contact KIHA's Housing Department to inquire about housing programs for non-AIAN applicants.

List ALL grants, scholarships, loans, gifts, or other financial aid you (the student) have received or will receive for this school year. Upload evidence of this assistance if available.

List everyone who lives in your home, starting with yourself. If you are living with your parents or another adult family member, you must list them too. Upload additional written information if necessary.

Please answer all of the following questions and provide detail as necessary. False or incomplete information may be considered fraud and carries serious consequences that can include fines or imprisonment.

Our Privacy Policy

Privacy Act Notice

Equal Opportunity Notice

Notice Regarding Fair Housing

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