Bia Form 6407 – Fill Out and Use This PDF

BIA Form 6407	OMB Control No. 1076-0184
ISSUED 11/10/2015	EXPIRATION DATE: 10/31/2018
	UNITED STATES DEPARTMENT OF THE INTERIOR
	BUREAU OF INDIAN AFFAIRS
	HOUSING ASSISTANCE APPLICATION

•All questions in this application must be answered. The requested information is self-explanatory.

•This application is subject to the Privacy Act of 1974, Pub. L. 93-579

A. APPLICANT INFORMATION_______________________________________________________

1.	Name:__________________	_______________________________		___________________
	Last	First	MI	Maiden Name (if any)
2.	Current Address: ____________________________________			___________________
	Street Address			P.O. Box # (if any)
	___________________________		__________________	___________________
	City		State	Zip Code

3.Telephone Number: (____)____________________________

4.	Date of Birth: ________________		5. Social Security Number: ______________________
6.	Tribe: _____________________________________________				Roll Number: ____________
	Reservation/Rancheria: _________________________________________________________
7.	Marital Status: ____Married	____Singled		____Widowed		____Other
	If you checked “Other”, please explain. ______________________________________________________________
8.	Are you Homeless? ____ No ____ Yes		9. Are you or spouse a Veteran? ____ No ____ Yes

Information About Spouse: __________________________________________________________

10.	Name:__________________	_________________		__	_______________________
	Last	First		MI	Maiden Name (if any)
11.	Date of Birth: ________________		12. Social Security Number: _____________________
13.	Tribe: _____________________________________________				Roll Number: ____________

B. FAMILY INFORMATION___________________________________________________________

List all other persons living in household on a permanent basis. Start with the oldest and provide Name, Date of Birth, Social Security Number, Relationship to Applicant, and Tribe/Roll Number .

Name	Date of Birth	Social Security #	Relationship to Applicant	Tribe/Roll Number

If you need more space, use a blank sheet of paper.

Date of this application:________

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BIA Form 6407	OMB Control No. 1076-0184
ISSUED 11/10/2015	EXPIRATION DATE: 10/31/2018

G.APPLICANT CERTIFICATION ____________________________________________________

(Read this certification carefully before you sign and date your application. Sign in ink).

I certify that all the answers given are true, complete and correct to the best of my knowledge and belief, and they are made in good faith. This certification is made with the knowledge that the information will be used to determine eligibility to receive financial assistance, and that false or misleading statements may constitute a violation of 18 U.S.C. 1001.

This application contains material covered by the Privacy Act. No record will be communicated to anyone or any agency unless requested in writing, by the applicant, or unless an officer or employee of the housing program or other Federal agency requires it in the performance of their duties.

Applicant’s Signature: ___________________________________	Date:	______________
Spouse’s Signature (if appropriate) _________________________	Date:	______________

PRIVACY ACT STATEMENT

25 CFR 265 and 25 U.S.C. 13 authorize the collection of this information. This information is covered by the system of record notice “Indian Housing Improvement Program, Interior, BIA-10.” The primary use of this information is to determine eligibility for assistance under the Housing Improvement Program. The records contained therein may only be disclosed in accordance with the routine uses and may not otherwise be disclosed by any means of communication to any person, or to another agency, except pursuant to a written request by, or with prior written consent of the individual to whom the record pertains. If the BIA uses the information furnished on this form for purposes other than those indicated above, it may provide you with an additional statement reflecting those purposes. Executive Order 9397 authorizes the collection of your Social Security number. Furnishing the information is voluntary but failure to do so may result in disapproval of your application.

PAPERWORK REDUCTION ACT STATEMENT

This information is being collected to select eligible families or individuals to participate in the Housing Improvement Program. Response to this request is required to obtain a benefit in accordance with 25 CFR 256. You are not required to respond to this collection of information unless it displays a currently valid OMB control number. This information will be used to determine the eligibility and the ranking of the applicant. Public reporting burden for this form is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining data, and completing and reviewing the form. Direct comments regarding the burden estimate or any other aspect of this form to Information Collection Clearance Officer – Indian Affairs, 1849 C Street, NW, MS-4141, Washington, DC 20240.

Date of this application:________

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