Housing Ap

Housing Application

* Indicates required field

Name *

First

Last

Street Address(P.O. Box) *

City *

State *

Zip *

Phone Number *

Have you ever participated in a Lovelock Paiute Tribe housing program? *

Family Composition

Name *

First

Last

Relationship *

D.O.B mm//dd/yyyy *

SSN: *

Name *

First

Last

Relationship *

D.O.B mm//dd/yyyy *

SSN: *

Name *

First

Last

Relationship *

D.O.B mm//dd/yyyy *

SSN: *

Name *

First

Last

Relationship *

D.O.B mm//dd/yyyy *

SSN: *

Name *

First

Last

Select One *

D.O.B mm//dd/yyyy *

SSN: *

Name *

First

Last

Relationship *

D.O.B mm//dd/yyyy *

SSN: *

Name *

First

Last

Relationship *

D.O.B mm//dd/yyyy *

SSN: *

Name *

First

Last

Relationship *

D.O.B mm//dd/yyyy *

SSN: *

* SSN is not required for any family members that are 6 year or younger*

Are you an enrolled member of the LPT ? *

Yes No

Are you or your spouse a person with a disability ? *

Yes No

Are any of your family members with a disability living in the home ? *

Yes No

Yes: which member *

Family Income

Name *

First

Last

Employer Information *

Line 1

Line 2

City

State

Zip Code

Country

Rate Per Hour *

Hour Per Week *

Name *

First

Last

Employer Information *

Line 1

Line 2

City

State

Zip Code

Country

Rate Per Hour *

Hours Per Week *

Name *

First

Last

Employer Information *

Line 1

Line 2

City

State

Zip Code

Country

Rate Per Hour *

Hour Per Week *

Name *

First

Last

Employer Information *

Line 1

Line 2

City

State

Zip Code

Country

Rate Per Hour *

Hours Per Week *

Other Income

Source *

monthly Income *

Source *

monthly Income *

Source *

monthly Income *

Other source of income includes but not limited to: Alimony, Relief, Service Allotment, Assistance From Relatives, Payments From Foster Children, Or any other regular source of income

Total Year Income *

Upload Documents *

Max file size: 20MB

*Please attach IRS 1040 and most recent pay stubs for all applicable family member.

Housing Conditions and Renovation Needs: *

* I understand that this application is not a contract and is not binding in any manner. I hereby authorize the Lovelock Paiute Tribe to obtain any and all information necessary for the purpose of verifying the statement above. I also understand that it is my responsibility to inform the Tribe in there is any changes to my family status along with reporting said changes to corresponding department. By submitting this form you agree.

Submit

Housing Department

Housing Application

Family Composition

Family Income

Other Income