YSHA Private Home Assistance Program
Contact: Tammy Rangel | Email: t.rangel@yshousing.org

PURPOSE:
The YSHA Housing Assistance Program is designed to provide minimal (emergency) repairs that may cause and/or a health and safety issue. This program is restricted to low-income applicants that own and occupy a private home for at least one year. (Utility services/hookup or connection fees are excluded from this program.)

Listing of Required Documentation for all applicants:
1. Applicant cannot be delinquent and/or have a debt with YSHA. (To become eligible - pay debt off or establish a
payback agreement prior to being assisted.)
2. Show proof of ownership through BIA land lease (for a minimal of 10 yrs.), home deed, yearly taxes, heir-ship, and
YSHA homeowner’s certificate.
3. Enrollment Verification - Abstract or Tribal ID. Must be a member of the Yankton Sioux Tribe.
4. Income Verification - For all permanent adult (18+) family members listed on application and must meet NAHASDA
income guidelines for the services you are applying for.
A. Earned Income - Copy of current paycheck stub.
B. Unearned Income - Copy of award letters, benefit statements - TANF, GA, SSI, and Unemployment.
5. Have an annual income as defined in the YSHA Admissions & Policy manual at or below 80% of median income.

Each participant will have an opportunity to apply every three years due to the limited funding for this program.

Authorization for the Release of Information Privacy Act Notice
Home Owners Application (Print Version)

Name

(Last, First, Middle)

Maiden Name

Current Mailing Address

(Address, City, State, Zip Code)

Physical Address

Physical residential address or directions to home:

Phone Number

Cell Phone Number

Message Phone Number

Marital Status

Single

Married

Divorced

Widowed

Other

Tribal Affiliation

Tribal Enrollment No.

Date requested

Check Request Information

Vendor:

Check Request Information

Amount

Check Request Information

Family Information

Please send copies of enrollment verification for all family members to YSHA. List all people living in your household on a permanent basis. Start with yourself, spouse, children and then all other adult members. Please include this information for all household members: Name (Last, First, Middle) | Relationship | Date of Birth | Sex | Social Security No. | Tribal Enrollment No.

Earned Income - Start with you then list all permanent household members with working income. Provide copies of current earned income such as check stubs, etc. to YSHA.

Name | Employment | Monthly Income

Unearned Income - Start with you then list all permanent household members with unearned income. Provide copies of current award letters and benefit statements for TANF, SSI, Unemployment, Pension, Annuity, Retirement, Child Support, Alimony, IIM, Per Capita, Pell Grants, etc. to YSHA.

Name | Source of Income | Monthly Income

Location of the house that requires assistance.

Give address and detailed directions to this house.

Provide a brief description of the problems you are experiencing with your house.

Have you ever received private home assistance? Application was known in the pas as emergency elderly assistance? Yes or No, if yes, when?

Is electricity available?

Yes

Number of Bedrooms?

House Size

Square Foot

Do you live in a house built with HUD funds? Yes or No, if yes, what year was it built?

Do the bathroom facilities in the house work? Yes or no. If no, Explain.

Does anyone in your family, who is permanent resident listed in this application, have severe health problems, handicap, or permanent disability? Yes/No If yes, name of family member and brief description of condition.

Applicant Certification

Please read this certification carefully before you sign and date your application. 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 USC 1001. This application contains material covered by the Privacy Act. No record will be communicated to anyone or any agency unless requested in writing either by the applicant or an officer or employee of the housing program or other federal agency requiring it in the performance of their duties.

Applicant Signature Date

YYYY

YSHA Private Home Assistance ProgramContact: Tammy Rangel | Email: t.rangel@yshousing.org

Yankton Sioux Housing Authority406 S Main Ave | Wagner, SD 57380605.384.3171Copyright 2024 Yankton Sioux Housing AuthorityWebsite Designed by Laken Design

YSHA Private Home Assistance Program
Contact: Tammy Rangel | Email: t.rangel@yshousing.org

Yankton Sioux Housing Authority
406 S Main Ave | Wagner, SD 57380
605.384.3171

Copyright 2024 Yankton Sioux Housing Authority
Website Designed by Laken Design