Items Required To Be Considered For HIP
1 (HIP) Application, BIA Form 6407
Name: Address: Phone:
Date Application issued to Applicant:
 		Date Application submitted:
Complete?
Yes No 		Date Letter of Determination or Letter of Deficiencies mailed to Applicant:
 Eligible?
Yes No
If Eligible What Category?
A B C
2 Applicant must Complete and sign BIA Form 6407.
Date Received by PW Housing:
 Eligibility Items Completed
Yes No 		If No, Date Application Mailed Back To Applicant:
 Eligibility Items Completed
Yes No
If No date returned to Applicant:
3 Applicant must provide copy of Certificate of Degree of Indian Blood or tribal membership card.
Date Received by PW Housing:
 Eligibility Items Completed
Yes No 		If No, Date Application Mailed Back To Applicant:
 Eligibility Items Completed
Yes No
If No date returned to Applicant:
4 Applicant must submit signed copies of current 1040 tax returns from all permanent members of the household including W-2's and all other attachments.
Date Received by PW Housing:
 Eligibility Items Completed
Yes No 		If No, Date Application Mailed Back To Applicant:
 Total of 1040 Tax Return Income for all permanent household members:
5 Applicant must provide proof of all "other income" from all permanent members of the household. this includes unearned income such as social security, general assistance, retirement, and unemployment benefits.
Date Received by PW Housing:
 Eligibility Items Completed
Yes No 		If No, Date Application Mailed Back To Applicant:
 Total of Other Income of all permanent household members:
6 If Applicant or other household members did not file a tax return, Applicant and other household members must submit a signed notarized statement explaining why you did not.
Date Received by PW Housing:
 Eligibility Items Completed
Yes No		 If No, Date Application Mailed Back To Applicant:
 What is total of other verified income documents for all permanent household members?
7 Applicant must furnish a copy of annual trust income statement from Individual Indian Money (IIM) account for royalty, lease, and other monies, from applicant's home agency. If no account, applicant must furnish a statement from you home agency to that effect.
Date Received by PW Housing:
 Eligibility Items Completed
Yes No 		If No, Date Application Mailed Back To Applicant:
8

Provide proof of ownership of the residence and/or land:

(1) For fee property, provide a copy of a fully executed warranty Deed, which is available at the local county court house.

(2) For trust property, provide certification from home agency.

(3) For tribally owned land, provide a copy of a properly executed tribal assignment, certified by the agency.

(4) For multi-owner property, provide a copy of a properly executed lease.

Date Received by PW Housing:
 Eligibility Items Completed
Yes No 		If No, Date Application Mailed Back To Applicant: