Oneida Nation | CHD Change Request Form

Head Of Household Information

First Name

Middle Name

Last Name

Alias/Maiden Name

Suffix

Date of Birth

Phone Number

Email Address

Tribal ID#

Social Security#

Marital Status

Single

Married

Divorced

Widowed

Separated

Mailing Address

Address 2

City

State

ZIP

SSN Verification

Preferred Method of Contact

Phone

Email

Mail

Are You A Veteran?

Yes

No

Do You Have Disability?

Yes

No

Emergency Contact

Name

Phone

Relationship

Email

Mailing Address

Payee Information

Name

Email

Phone

Mailing Address

Choose Request Type

Report Change To Household

Complete Annual Renewal

Household Income

Income includes, but is not limited to, employment income, self-employment income, benefit payments (SSD, SSI), Veterans benefits, welfare assistance (GA, TANF), alimony and/or child support, interest and/or dividends from assets, or any other income or money that a household member regularly earns or receives. New or employment ending you must provide Employer Verification Form, and once you have received 30 days of paystubs must be submitted.

No

Yes

Did anyone in your household accept GWA payments in 2023?

No

Yes

Do you have a source of income to report in your household?

Name

Income Source

Monthly Gross Amount

Start Date

Stop Date

Income Verification

If you are currently self-employed, we kindly request that you download the SEI Form and complete it in its entirety. Alternatively, if you have recently commenced employment, please download and complete the Employment Verification form.

Household Expenses

Allowable expenses include the actual cost of childcare and medical expenses that you pay for out of your own pocket (not covered by insurance or other sources) that exceed 3% of your annual income. Child Care expenses must be verified with form. Medical expenses must provide receipts.

No

Yes

Do you have any ongoing expenses for your household?

Member Name

Expense Description

Monthly Payment Amount

Provider Name

Expense Verification

Household Higher Education

Educational scholarships and grants must be on file if you are receiving. This does not effect your monthly rent and is not considered as income. You will need to provide Financial Aid Award Letter for all household members attending higher education.

No

Yes

Do you have anyone in your household currently enrolled in higher educational institutions?

Member Name

Graduation Date

Student Status

Full-time

Part-time

Education Letters or Awards

Criminal Activity/Status

Criminal convictions related to drugs (within 3 years), felony (within 5 years), or act of violence (within 2 years) are not eligible for participation in the rental programs, provided that the Pardon and Forgiveness law may provide an exception to the conditions.

No

Yes

Does anyone in your household have a criminal conviction?

Member Name

Conviction State

Conviction County

Conviction Date

Charges

Household Pets

May keep pets on the premises in accordance with the Nation's Domestic Animals law provided that an increased security deposit is required. Pet Agreement will need to be completed and provided to Landlord. Required pet deposit of $200 per animal.

No

Yes

Do you have pets in your household?

Pet Name

Pet Type

Pet License Number

Service Pet ID#

Service Pet ID Verification

Authorization for Release of Information

I, the undersigned, hereby authorize and direct any agencies, offices, groups, organizations, business or individuals to furnish information concerning myself and/or my household to the Comprehensive Housing Division (CHD), its duly authorized representative and/or its contracted agency for purpose of verifying my eligible to receive benefits from CHD.

Any individual or organization including any governmental agency may be asked to release information including, but not limited to: courts, law enforcement agencies, background screening agencies, employers, State Unemployment Agency, previous landlords, support and alimony providers, Social Security Administration, U.S. Department of Veterans Affairs, utility companies, medical professionals and facilities, child care providers, banks and other financial institutions, credit reporting agencies, social service and welfare agencies, public housing agencies, retirement systems, and schools/colleges.

I understand that, depending on program policies and requirements, verifications and inquiries that may be requested included, but are not limited to: identity, employment, income, marital status, residential history, household composition, medical expenses, assets, debts, credit history, criminal history, financial benefits, and school enrollment.

I agree that the Oneida Nation and CHD may conduct computer matching programs with other governmental agencies including federal, state, tribal, or local agencies. The government agencies include but are not limited to: U.S. Office of Personnel Management, U.S. Social Security Administration, U.S. Department of Defense, U.S. Postal Service, State Employment Security Agencies, and State Welfare and Food Stamp Agencies. The match will be used to verify information supplied by the applicant.

I understand that I have a right to review any information received in accordance with my release and have a right to correct any information that I can prove is correct.

I acknowledge that a photocopy or facsimile copy of this authorization may be deemed the equivalent of the original and may be used as a duplicate original.

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate 12 months from the date signed.

I understand that if I, or any adult household member, fail to sign this authorization, or revoke this authorization prior to completion of necessary verifications and inquiries, it may constitute grounds for denial or termination of assistance or tenancy or both.

Certify

I/We certify that the above information provided is true and correct to the best of my knowledge. I/We understand that false statements or information is punishable under Federal Law. I/We also understand that false statements or information is grounds for termination of rental agreement and eviction from the premises. I/We also understand that it is my/our responsibility and obligation to promptly report any further changes in my household income, assets, expenses, and/or household composition as soon as they occur.