KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, AK (907) or (800) within Alaska

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1 KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, AK (907) or (800) within Alaska Information required with Student Rental Assistance Application The following information will be needed to determine your eligibility for our Student Rental Assistance Program, please provide: 1. Proof of Income. If you live with your parents and they claim you on their income tax as a dependent, you must supply a copy of your parent s last year s income tax return. If you were not claimed as a dependent by your parents on their last year s tax return, or you have not lived with your parents for over 12 months, we will use your income to determine your eligibility. Please provide a copy of your last year s tax return. 2. *Proof of Alaska Native or American Indian Blood Provide Certification of Indian Blood issued by BIA or other documents from your Tribe certifying your blood quantum or a document stating: The owner of this certification is an Alaska Native as defined by Section 3(b) of the Alaska Native Claims Settlement Act of 1971, as amended by Public Law , passed February 3,1988. Or provide evidence that you are a descendant of someone who can provide the other documentation. 3. *Proof you reside on Kodiak Island. Provide proof you are a resident of a community on Kodiak Island. This can be a ID showing your address, a rent receipt, utility bill, or other documents that show your residence address, or a statement from a reliable source attesting to the fact that you have lived on Kodiak Island for at least the past 6 months. 4. Evidence of enrollment as a full time student. Vocational schools will need to provide a written statement with the dates you are enrolled as full time student. 5. Proof of any Student Aid you will be receiving. Provide a copy of any award letters that verify the amounts and the sources of all student financial assistance you will be receiving. 6. Proof of School Costs. Provide something in writing from your school that outlines your expenses, i.e. room and board, tuition, books, fees, etc. 7. Proof of rent amount. If you will be living off campus, you must provide a copy of your rent or lease agreement listing all persons who will share the rental unit. If you will be residing on campus, provide a copy of the campus agreement (additional forms will be provided to you for the landlord or school to complete upon approval of your application). 8. If you were a participant last year, your eligibility for assistance this year will require a GPA of 2.0. Provide evidence of last years GPA. *If you were a participant last year we will have these items on file and you will not need to provide them with this application. If it has been over one year since you applied for the Student Rental Assistance Program you will need to provide this information.

2 KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, ALASKA (907) or (800) REPORTING YOUR INCOME Applicants for assisted housing programs are REQUIRED to fully disclose and report assets and all income or money received by the household, no matter the source. You MUST report all assets and income at initial application, on every annual recertification, and when there is a change in your income. Changes in income must be reported in writing WITHIN TEN (10) DAYS of your knowing about the change. FAILURE TO REPORT ASSETS OR INCOME, DELIBERATE MISREPRENSENTATION OF ASSETS OR INCOME, AND/OR FALSIFYING INCOME IS FRAUDULENT AND A CRIME. If you fail to report and disclose your assets and income as required, you may be: Prosecuted for fraud Your application may be denied for up to 3 years Failure to report any changes in income, assets or family composition, as required, shall be cause for retroactive rent charges and/or termination of a lease agreement. DO NOT risk your opportunity to receive housing assistance by failing to disclose your income.

3 Kodiak Island Housing Authority Program Limits The following income limits are the maximum for each program. Your total yearly gross income may not exceed these limits to be eligible. Family Size All Programs 1 $40,800 2 $46,650 3 $52,450 4 $58,300 5 $62,950 6 $67,650 7 $72, $76,950 How do you file a housing application? You are required to complete an application form. Do not leave any section blank. Mark N/A if the section does not apply. The head of household and other adults must sign the application when it is complete. We will assist you with any questions or concerns you may have in completing your application. An incomplete application will delay your eligibility. What information is verified or checked for my housing application? The following information will be verified: Family income, assets, social security numbers, immigration (alien) status, identity of adults, age and relationship of person listed on application if questionable, preference status (if claimed), and/or Alaska Native/American Indian Status (if claimed for preference in admission). Other information that may be checked includes: * Criminal History * Prior landlord references * Personal references * Past participation in Federal Housing * Credit History When will I hear on my application? You will be notified of your eligibility. Questions about your application can be answered be calling or Verbal and/or Written notification of offer will be provided. We require a face-to-face interview with applicant prior to move in.

4 KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD, KODIAK, AK Time Rcvd OR TOLL FREE Staff Initials APPLICATION FOR STUDENT RENTAL ASSISTANCE Please answer ALL questions below! Incomplete information will delay the processing of your application. ALL information is subject to investigation and verification. Non-Native/ Non-Indian applicants are ineligible. This program is funded through the Native American Housing Assistance and Self Determination Act of ************************************************************************************** APPLICANT: STUDENT S FULL NAME: TELEPHONE NUMBER: MAILING ADDRESS: RESIDENCE ADDRESS: school starts: FAMILY INFORMATION: Must be provided for all family members unless student is legally emancipated or has not lived with family for over 1 year and not been claimed on parents most recent income tax return. *List the Student First LEGAL NAME (LAST, FIRST) DATE OF BIRTH SEX RELATION- SHIP TO APPLICANT SOCIAL SECURITY NUMBER Is person a U.S. Citizen? Self IF YOU (the student) ARE MARRIED AND HAVE NOT LISTED YOUR SPOUSE, PLEASE EXPLAIN WHY.. Explanation: Spouse s name & address: Please list all other names used by you or other adults (18 and over).

5 NATIVE PREFERENCE Effective October 1,1997, KIHA is required to provide assistance only to applicants who are Alaska Native/American Indian. Do you claim this preference? Yes No If yes, please list names of household members who qualify for the Alaska Native Indian preference. State the Alaska Village or Alaska Tribal affiliation for each named individual (proof is required). The affiliation can be an Alaska Native Regional Corporation or Village Corporation in which the individual or their parents/grandparents own or owned stock in applicable. If the household member is known in the village or the region by another name, state that name. NAME TRIBE/VILLAGE/ANCSA CORPORATION AFFILIATION HAVE YOU OR A MEMBER OF YOUR HOUSEHOLD EVER BEEN CONVICTED OF ANY CRIME OTHER THAN A TRAFFIC VIOLATION? YES NO IF YES, PLEASE EXPLAIN HAVE YOU OR YOUR PARENTS EVER PARTICIPATED IN ANY FEDERALLY SUBSIDIZED HOUSING PROGRAMS? YES NO IF YES, FROM TO ; NAME OF HOUSING AUTHORITY CITY & STATE: DO YOU OR YOUR PARENTS OWE MONEY TO KIHA OR TO ANOTHER HOUSING AGENCY? Yes No PLEASE EXPLAIN: FAMILY INCOME: Must be provided for all members unless student is legally emancipated or has not lived with family for over 1 year and not been claimed on parents most recent income tax return. FAMILY MEMBER NAME EMPLOYER\INCOME SOURCE HOURLY RATE WEEKLY RATE MONTHLY AMOUNT YEAR TO DATE AMT. IS ANYONE SELF EMPLOYED? YES NO IF YES, WHAT TYPE OF BUSINESS?

6 WHICH FAMILY MEMBERS RECEIVED THE ALASKA PERMANENT FUND DIVIDEND? ASSETS: Identify assets owned by you or your family in the section below. If you answer yes, please provide complete information. Include assets of all family members. If you have not lived with your family for 1 year, list only your assets. YES NO ASSET VALUE NATIVE CORPORATION STOCK OR OTHER STOCK: (list for all family members) Number of Shares: In whose name? Corporation Name: Number of Shares: In whose name? Corporation Name: Number of Shares: In whose name? Corporation Name: BANK ACCOUNTS: (list for all family members) Name of Bank: Name of Bank: Name on Acct: Name on Acct: Type of Acct: Type of Acct: Account Number: Account Number: Name of Bank: Name on Account: Type of Acct: Account Number: Name of Bank: Name on Account: Type of Acct: Account Number: REAL PROPERTY: (Provide copy of last assessment) Owner of property: Location of property: LIFE INSURANCE (Other than term) Provide copy of last statement STOCKS/BONDS: (Include US Savings Bonds, provide copy of bonds and most recent statement of stock value) OTHER INVESTMENTS: (IRA s, retirement accounts or the like) OTHER ASSETS: (please describe) Have you sold or given away any asset in the past two years? Yes No If yes, explain: School Information: List the name and address of the school you will be attending for school year (proof of enrollment required). List any loans, grants, scholarships or financial aid you (the student) have received or expect to receive for this school year. Give identifying information and amounts. If you have a financial aid application filed with your school, please provide a copy. Any letter or notice of financial aid award must also be provided. (Proof of all financial aid is required) Type of Financial Aid Source Amount

7 Housing costs for school year Please list your housing costs for the school. This can be information provided by your school, or if you will be living off campus, a copy of your rent or lease agreement. Proof of housing costs is required. TYPE AMOUNT APPLICANTS CERTIFICATION I\We certify that the information given to the Kodiak Island Housing Authority on the application is accurate and complete to the best of my knowledge and belief. I\We understand that false statements or information is punishable under Federal Law. I\We also understand that giving false statements or information is grounds for termination of housing assistance and termination of occupancy Signature of Student Signature of Parent Signature of Parent Kodiak Island Housing Authority does not discriminate against any person because of race, color, religion, sex, handicap, familial status or national origin. We do business in accordance with the Federal Fair Housing Law. If you believe you have been discriminated against, you may call the Fair Housing & Equal Opportunity National Toll-Free Hot Line at or dial Notice: Any attempt to obtain Federal housing, any rent subsidy or rent reduction by false information, impersonation, failure to disclose, or other fraud (and any act of assistance to such attempt) is a crime. EQUAL HOUSING OPPORTUNITY We Do Business in Accordance With the Federal Fair Housing Law

8 Alaska Department of Revenue Permanent Fund Dividend Division Request for Income Verification Use this form only if you or the child(ren) you sponsored did not receive a Permanent Fund Dividend. (If you were garnished do not use this form as you must report the full amount as income) Your First Name MI Last Name Social Security Number of Birth Daytime Telephone Number Message Telephone Number I did not receive a PFD for the following year The child(ren) listed below whom I sponsored did not receive a PFD for the following year Your First Name MI Last Name Social Security Number of Birth (MM/DD/YY) Child s First Name MI Last Name Social Security Number of Birth (MM/DD/YY) Child s First Name MI Last Name Social Security Number of Birth (MM/DD/YY) Child s First Name MI Last Name Social Security Number of Birth (MM/DD/YY) Child s First Name MI Last Name Social Security Number of Birth (MM/DD/YY) Child s First Name MI Last Name Social Security Number of Birth (MM/DD/YY) Your Signature is Required I authorize the Permanent Fund Dividend Division to release of information regarding the status of my PFD to the following Your Signature Housing Agency send or deliver this completed form to the Juneau Dividend Information Office listed below: For PFD Office Use ONLY Correct, applicant(s) did not receive a PFD Incorrect, applicant(s) received a PFD Amount Signature of PFD Rep. Alaska Department of Revenue Permanent Fund Dividend Division PO Box Juneau, AK Send all self addressed envelope with this request Verf Request (New 8/02)

9 KODIAK ISLAND HOUSING AUTHORITY 3137 Mill Bay Road, Kodiak, AK Phone Fax : Dear Sirs: We are required to verify the incomes of all members of families applying for admission in the Federally Assisted Housing Programs we operate, and periodically to re-examine family incomes. To comply with this requirement, we ask your cooperation in supplying the information requested below regarding the referenced individual. This information will be used only in determining the eligibility status and monthly payment. I authorize the release of the above requested information: Signature APPLICANT - DO NOT WRITE BELOW THIS LINE Please provide the amount of Native Corporation Stock Disbursement issued to: SS# and the date issued for the past twelve (12) months. Amount of Distribution $ $ $ $ Issued Your prompt return of this letter is appreciated. This above recipient s housing assistance will be pending until this information is received. Sincerely, Cc: file

10 Authorization for the Release of Information/ Privacy Act Notice to the U.S. Department of Housing and Urban Development (HUD) and the Housing Agency/Authority (HA) U.S. Department of Housing and Urban Development Office of Public and Indian Housing PHA requesting release of information; (Cross out space if none) (Full address, name of contact person, and date) IHA requesting release of information: (Cross out space if none) (Full address, name of contact person, and date) Authority: Section 904 of the Stewart B. McKinney Homeless Assistance Amendments Act of 1988, as amended by Section 903 of the Housing and Community Development Act of 1992 and Section 3003 of the Omnibus Budget Reconciliation Act of This law is found at 42 U.S.C This law requires that you sign a consent form authorizing: (1) HUD and the Housing Agency/Authority (HA) to request verification of salary and wages from current or previous employers; (2) HUD and the HA to request wage and unemployment compensation claim information from the state agency responsible for keeping that information; (3) HUD to request certain tax return information from the U.S. Social Security Administration and the U.S. Internal Revenue Service. The law also requires independent verification of income information. Therefore, HUD or the HA may request information from financial institutions to verify your eligibility and level of benefits. Purpose: In signing this consent form, you are authorizing HUD and the above-named HA to request income information from the sources listed on the form. HUD and the HA need this information to verify your household s income, in order to ensure that you are eligible for assisted housing benefits and that these benefits are set at the correct level. HUD and the HA may participate in computer matching programs with these sources in order to verify your eligibility and level of benefits. Uses of Information to be Obtained: HUD is required to protect the income information it obtains in accordance with the Privacy Act of 1974, 5 U.S.C. 552a. HUD may disclose information (other than tax return information) for certain routine uses, such as to other government agencies for law enforcement purposes, to Federal agencies for employment suitability purposes and to HAs for the purpose of determining housing assistance. The HA is also required to protect the income information it obtains in accordance with any applicable State privacy law. HUD and HA employees may be subject to penalties for unauthorized disclosures or improper uses of the income information that is obtained based on the consent form. Private owners may not request or receive information authorized by this form. Who Must Sign the Consent Form: Each member of your household who is 18 years of age or older must sign the consent form. Additional signatures must be obtained from new adult members joining the household or whenever members of the household become 18 years of age. Persons who apply for or receive assistance under the following programs are required to sign this consent form: PHA-owned rental public housing Turnkey III Homeownership Opportunities Mutual Help Homeownership Opportunity Section 23 and 19(c) leased housing Section 23 Housing Assistance Payments HA-owned rental Indian housing Section 8 Rental Certificate Section 8 Rental Voucher Section 8 Moderate Rehabilitation Failure to Sign Consent Form: Your failure to sign the consent form may result in the denial of eligibility or termination of assisted housing benefits, or both. Denial of eligibility or termination of benefits is subject to the HA s grievance procedures and Section 8 informal hearing procedures. Sources of Information To Be Obtained State Wage Information Collection Agencies. (This consent is limited to wages and unemployment compensation I have received during period(s) within the last 5 years when I have received assisted housing benefits.) U.S. Social Security Administration (HUD only) (This consent is limited to the wage and self employment information and payments of retirement income as referenced at Section 6103(l)(7)(A) of the Internal Revenue Code.) U.S. Internal Revenue Service (HUD only) (This consent is limited to unearned income [i.e., interest and dividends].) Information may also be obtained directly from: (a) current and former employers concerning salary and wages and (b) financial institutions concerning unearned income (i.e., interest and dividends). I understand that income information obtained from these sources will be used to verify information that I provide in determining eligibility for assisted housing programs and the level of benefits. Therefore, this consent form only authorizes release directly from employers and financial institutions of information regarding any period(s) within the last 5 years when I have received assisted housing benefits. Original is retained by the requesting organization. ref. Handbooks , , & form HUD-9886 (7/94)

11 Consent: I consent to allow HUD or the HA to request and obtain income information from the sources listed on this form for the purpose of verifying my eligibility and level of benefits under HUD s assisted housing programs. I understand that HAs that receive income information under this consent form cannot use it to deny, reduce or terminate assistance without first independently verifying what the amount was, whether I actually had access to the funds and when the funds were received. In addition, I must be given an opportunity to contest those determinations. This consent form expires 15 months after signed. Signatures: Head of Household Social Security Number (if any) of Head of Household Other Family Member over age 18 Spouse Other Family Member over age 18 Other Family Member over age 18 Other Family Member over age 18 Other Family Member over age 18 Other Family Member over age 18 Privacy Act Notice. Authority: The Department of Housing and Urban Development (HUD) is authorized to collect this information by the U.S. Housing Act of 1937 (42 U.S.C et. seq.), Title VI of the Civil Rights Act of 1964 (42 U.S.C. 2000d), and by the Fair Housing Act (42 U.S.C ). The Housing and Community Development Act of 1987 (42 U.S.C. 3543) requires applicants and participants to submit the Social Security Number of each household member who is six years old or older. Purpose: Your income and other information are being collected by HUD to determine your eligibility, the appropriate bedroom size, and the amount your family will pay toward rent and utilities. Other Uses: HUD uses your family income and other information to assist in managing and monitoring HUD-assisted housing programs, to protect the Government s financial interest, and to verify the accuracy of the information you provide. This information may be released to appropriate Federal, State, and local agencies, when relevant, and to civil, criminal, or regulatory investigators and prosecutors. However, the information will not be otherwise disclosed or released outside of HUD, except as permitted or required by law. Penalty: You must provide all of the information requested by the HA, including all Social Security Numbers you, and all other household members age six years and older, have and use. Giving the Social Security Numbers of all household members six years of age and older is mandatory, and not providing the Social Security Numbers will affect your eligibility. Failure to provide any of the requested information may result in a delay or rejection of your eligibility approval. Penalties for Misusing this Consent: HUD, the HA and any owner (or any employee of HUD, the HA or the owner) may be subject to penalties for unauthorized disclosures or improper uses of information collected based on the consent form. Use of the information collected based on the form HUD 9886 is restricted to the purposes cited on the form HUD Any person who knowingly or willfully requests, obtains or discloses any information under false pretenses concerning an applicant or participant may be subject to a misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages, and seek other relief, as may be appropriate, against the officer or employee of HUD, the HA or the owner responsible for the unauthorized disclosure or improper use. Original is retained by the requesting organization. ref. Handbooks , , & form HUD-9886 (7/94)

12 Kodiak Island Housing Authority 3137 Mill Bay Road Kodiak, Alaska Phone: (907) Fax: (907) Authorization for Release of Information Head of Household: Client No.: I authorize and direct any federal, state or local agency and any organization, business, or individual to Kodiak Island Housing Authority (KIHA) any information or materials needed to complete and verify my application for, or participation in, any KIHA housing program. Verifications and inquiries that may be requested include but are not limited to: * IDENTITY AND MARITAL STATUS * INCOME FROM ANY SOURCE * CREDIT HISTORY * ASSETS OF ANY KIND, INCLUDING ASSETS * POLICE RECORDS AND CRIMINAL HISTORY ASSETS DISPOSED OF WITHIN THE LAST * EMPLOYMENT INCOME TWO (2) YEARS * RESIDENCES AND RENTAL ACTIVITY * MEDICAL OR CHILD CARE ALLOWANCES Groups or Individuals That KIHA May Contact * PAST AND PRESENT LANDLORDS * PAST AND PRESENT EMPLOYERS * COURTS AND POST OFFICES * DEPT. OF HEALTH & SOCIAL SERVICES * SCHOOLS AND COLLEGES * DEPT. OF LABOR AND WORKFORCE * LAW ENFORCEMENT AGENCIES DEVELOPMENT * UTILITY COMPANIES * DEPT. OF EDUCATION & EARLY * VETERANS ADMINISTRATION DEVELOPMENT * BANKS AND FINANCIAL INSTITUTIONS * SOCIAL SECURITY ADMINISTRATION * AK PERMANENT FUND CORPORATION * MEDICAL AND CHILD CARE PROVIDERS * PRIVATE SOCIAL SERVICE AGENCIES * RETIREMENT SYSTEMS * INDIVIDUALS PROVIDING REFERENCES OR * PAYEES, TRUSTEES OTHER DOCUMENTATION * CREDIT REPORTING COMPANIES Conditions: I understand that this authorization cannot be used to obtain any information about me that is not pertinent to my eligibility for, and continued participation in, a housing program. I agree that a photocopy of this authorization may be used for the purposes stated above. This authorization will stay in effect for 15 months from the date signed. Signature of Head of Household Print Name Signature of Spouse/Co-Tenant Print Name Signature of Adult Member Print Name

13 Giving True and Complete Information KODIAK ISLAND HOUSING AUTHORITY 3137 Mill Bay Road, Kodiak, AK Phone: Fax: APPLICANT\TENANT CERTIFICATION I/we certify that all the information provided about household composition, Social Security numbers, U.S. Citizenship, income, family assets and items for allowance and deductions, is/are accurate and complete to the best of my/our knowledge. I/we certify that the information given is true and correct. Reporting Changes in Income or Household Composition I/we know I/we am/are required to report within 10 days, in writing, any changes in income and any changes in household size (when a person moves in or out of the unit). I/we understand the rules regarding guests\visitors for current KIHA programs and that I/we must report anyone who is staying with me/us. Reporting on Prior Housing Assistance I/we certify that I/we have disclosed where I/we received any previous Federal housing assistance and whether (if) I/we owe any money to another Federal program. I/we certify that, for this previous Federal assistance, I/we did not commit any fraud, knowingly misrepresent any information, or vacant (vacate) the unit in violation of the lease. No Duplicate Residence or Assistance Cooperation I/we certify that the house or apartment for which I/we will receive assistance from KIHA, or for which I/we am/are currently receiving assistance from KIHA, will be my/our principal residence. I/we will not obtain duplicate Federal housing assistance while I/we am/are in this current program. I/we will not live anywhere else without notifying KIHA immediately in writing. I/we will not sublease my/our assisted residence. I/we know I/we am/are required to cooperate in supplying all information needed to determine my/our eligibility, level of benefits, or verification of my true circumstances. Cooperation includes attending pre-scheduled meetings and completing and signing needed forms. I/we understand failure or refusal to do so may result in delays, denial of assistance, termination of assistance, or eviction. Criminal and Administrative Action for False Information I/we understand that knowingly supplying false, incomplete or inaccurate information is punishable under Federal or State criminal law. I/we understand that knowingly supplying false, incomplete, or inaccurate information is grounds for denial of assistance, termination of housing assistance and/or termination of tenancy. Signature and of Household Adults 1. : 2. : 3. :

14 KODIAK ISLAND HOUSING AUTHORITY 3137 MILL BAY ROAD KODIAK, ALASKA DECLARATION OF CITIZEN OR NON-CITIZEN STATUS Notice to applicants and tenants: In order to be eligible to receive the housing assistance sought, each applicant for, or recipient of, housing assistance must be lawfully within the U.S. Please read the Declaration statement carefully and sign and return to the Housing Authority at 3137 Mill Bay Road, Kodiak, Alaska Please feel free to consult with an immigration lawyer or other immigration expert of your choosing. I, certify, under penalty of perjury 1/, that, to the best of my knowledge, I am lawfully within the United States because (please check the appropriate box): I am a citizen by birth, a naturalized citizen or a national of the United States; or I have eligible immigration status that I am 62 years of age or older. Attach evidence of proof of age 2/; or I have eligible immigration status as checked below (see reverse side of this form for explanations). Attach INS document(s) evidencing eligible immigration status and signed verification consent form. Immigration status under 101(a)(15) or 101(a)(20) of the Immigration and Nationality Act (INA) 3/; or Permanent residence under 249 of INA 4/; or Refugee, asylum, or conditional entry status under 207, 208 or 203 of the INA 5/; or Parole status under 212(d)(5) of the INA 6/; or Threat to life or freedom under 243(h) of the INA 7/; or Amnesty under 245A of the INA 8/. (Signature of Family Member) () Check box on left if signature is of adult residing in the unit who is responsible for child named on statement above. HA: Enter INS\SAVE Primary Verification #: : 1/ Warning: 18 U.S.C provides, among other things, that whoever knowingly and willfully makes or uses a document or writing containing any false, fictitious, or fraudulent statement or entry, in any matter within the jurisdiction of any department or agency of the United States, shall be fined not more than $10,000, imprisoned for not more than five years, or both. The following footnotes pertain to non-citizens who declare immigration status in one of the following categories:

15 2/ Eligible immigration status and 62 years of age or older. For non-citizens who are 62 years of age or older or who will be 62 years of age or older and receiving assistance under a Section 214 covered program on June 19, If you are eligible and elect to select this category, you must include a document providing evidence of proof of age. No further documentation of eligible immigration status is required. 3/ Immigration status under 101(a)(15) or 101(a)(20) of INA. A non-citizen lawfully admitted for permanent residence, as defined by 101(a)(20) of the Immigration and Nationality Act (INA), as an immigrant, as defined by 101(a)(15) of the INA (8 U.S.C. 1101(a)(20) and 1101(a)(15), respectively [immigrant status]. This category includes a non-citizen under 210 or 210A or the INA (8 U.S.C or 1161), [special agricultural worker status], who has been granted lawful temporary resident status. 4/ Permanent residence under 249 of INA. A non-citizen who entered the U.S. before January 1, 1972, or such mater date as enacted by law, and had continuously maintained residence in the U.S. since then, and who is not ineligible for citizenship, but who is deemed to be lawfully admitted for permanent residence as a result of an exercise of discretion by the Attorney General under 249 of the INA (8 U.S.C 1259) [amnesty granted under INA 249]. 5/ Refugee, asylum, or conditional entry status under 207, 208 or 203 of INA. A non-citizen who is lawfully present in the U.S. pursuant to an admission under 207 of the INA (8 U.S.C. 1157) [refugee status]; pursuant to the granting of asylum (which has not been terminated) under 208 of the INA (8 U.S.C. 1158) [asylum status]; or as a result of being granted conditional entry under 203(a)(7) of the INA (U.S.C. 1153(a)(7) before April 1, 1980, because of persecution or fear of persecution on account of race, religion, or political opinion or because of being uprooted by catastrophic national calamity [conditional entry status]. 6/ Parole status under 212(d)(5) of INA. A non-citizen who is lawfully present in the U.S. as a result of an exercise of discretion by the Attorney General for emergent reasons or reasons deemed strictly in the public interest under 212(d)(5) of the INA (8 U.S.C. 1182(d)(5)) [parole status]. 7/ Threat to life or freedom under 243(h) of INA. A non-citizen who is lawfully present in the U.S. as a result of the Attorney General's withholding deportation under 243(h) of the INA (8 U.S.C. 1253(h)) [threat to life or freedom]. 8/ Amnesty under 245A of INA. A non-citizen lawfully admitted for temporary or permanent residence under 245A of the INA (8 U.S.C. 1255a) [amnesty granted under INA 245A]. Instructions to Housing Authority: Following verification of status claimed by persons declaring eligible immigration status (other than for non-citizens age 62 or older and receiving assistance on June 19, 1995), HA must enter INS SAVE Verification Number and date that it was obtained. A HA signature is not required. Instructions to Family Member For Completing Form: On opposite page, print or type first name, middle initial(s), and last name. Place an "X" or " " in the appropriate boxes. Sign and date at bottom of page. Place an "X" or " " in the box below the signature if signature is by the adult residing in the unit who is responsible for Child.