Please send completed applications and copies of supporting documents to: Sanitation Program ACFS 2218 Shunk Road Sault Ste.

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1 SANITATION PROGRAM APPLICATION INSTRUCTION SHEET WARNING! TITLE 18, SECTION 1001 OF THE UNITED STATES CODE, STATES THAT A PERSON IS GUILTY OF A FELONY FOR KNOWINGLY AND WILLINGLY MAKING FALSE OR FRAUDULENT STATEMENTS TO ANY DEPARTMENT OR AGENCY OF THE UNITED STATES. Penalties for committing fraud: If your application or updated information contains false or incomplete information, you may be: Required to repay all monies expended on your home by the Sault Ste. Marie Tribe of Chippewa Indians. Fined up to $10, Imprisoned for up to 5 years; and/or Prohibited from receiving future assistance. Your State and local governments may have other laws and penalties as well. Completing the Application When you give your answers to application questions, you must include the following information: Income (You must submit three current stubs from all sources that you have). All sources of money you or any family member receives (wages, welfare payments, alimony, social security, pension, etc.); INCLUDE CURRENT YEAR COPIES OF W-2 S and 1040 showing refund (only accepted prior to July 1 st.) Any money you receive on behalf of your children (child support, social security for children, etc.) Income from assets (interest from a saving account, credit union, or certificate of deposit, dividends from stocks, etc.) Any anticipated income (such as a bonus or pay raise or settlements you expect to receive). Family/Household Members The names of all of the people (adults and children) who will actually be living with you on a year round basis, whether or not they are related to you. Handicapped If you answer yes to being handicapped, we need a statement from your physician stating that the handicap is permanent, whether it prevents you from working, and what your handicap is. Tribal Card and Social Security Card (required) Applicant must possess a valid Tribal card and must submit a copy of their social security card. Registered Deed The recorded deed must be in the applicant's (Tribal Member's) name. Lien A 5 year lien will be placed on the home for the total allocated cost of work. Land Taxes Provide proof of paid land taxes for the year. Insurance Provide proof of paid homeowners insurance for the year. Picture Provide the Sanitation Office a current picture of the site to be serviced. Plat Map Provide a location map from the Plat book showing location of home site, and showing distances and directions from known paved arterial road. Hand Drawing of Site Provide the Sanitation Office with a hand drawing of the site to be serviced. YOUR APPLICATION WILL NOT BE PROCESSED IF ALL THE ABOVE INFORMATION IS NOT COMPLETED OR TURNED IN. Please send completed applications and copies of supporting documents to: Sanitation Program ACFS 2218 Shunk Road Sault Ste. Marie, MI 49783

2 SANITATION APPLICATION * All questions in this application must be answered or your application will be returned for completion. Read instructions before completing this form. * This application is subject to the Privacy Act of 1974, Pub. L * Read the certification carefully before you sign and date your application. Sign in ink. A. APPLICANT INFORMATION: 1. NAME Last First Middle Maiden (if applicable) 2. CURRENT ADDRESS: 3. TELEPHONE NO. COUNTY: 4. DATE OF BIRTH 4. SOC. SEC. NO.(Mandatory) 5. MARITAL STATUS Married Single Widowed Other If you checked "other" please explain. 6. SPOUSES NAME Last First Middle Maiden (if applicable) 7. DATE OF BIRTH 8. SOC. SEC. NO(mandatory). B. FAMILY INFORMATION: List all other persons living in household on a permanent basis starting with the eldest: NAME DATE OF BIRTH RELATIONSHIP TO APPLICANT TRIBE AND ROLL NUMBER SOCIAL SECURITY NUMBER IF YOU NEED MORE SPACE, USE A BLANK SHEET OF PAPER C. INCOME INFORMATION:

3 1. Earned Income: Start with applicant then list ALL permanent family members 18 years old and above, who are listed under Part B and have earned income. Provide W-2 forms, wage stubs, etc., for verification. NAME ANNUAL INCOME SOURCE TOTAL ANNUAL EARNED INCOME...$ 2. Unearned Income: Start with applicant then list ALL permanent family members, who are listed under Part B and have unearned income such as social security, retirement, disability and unemployment benefits, child support and alimony, royalties, per capita payments, interest, etc. Provide check stubs, statements, Individual Indian Money(IIM) ledgers, etc. for verification. Please attach copies of bank statements for saving/checking accounts. Include all money in stocks & bonds. NAME ANNUAL INCOME SOURCE TOTAL ANNUAL UNEARNED INCOME...$ TOTAL COMBINED ANNUAL INCOME(earned + unearned)...$

4 D. SERVICES REQUESTING: 1. Services your requesting? [ ]Well [ ]Water Pressure System [ ]Septic Tank Drainfield [ ]Community Water Services [ ]Community Sewer Service. 2. Have you been serviced by IHS before? [ ]No [ ]Yes Project No. 3. Has the house site ever been serviced before? [ ]No [ ]Yes If yes, under who's name: E. HOUSING INFORMATION: 1. Is your home a mobile home? [ ]Yes [ ]No Size of Home X If you answer yes, complete Sections 1 A,B,C and skip down to Section 4. A. Is the mobile home new to the site? [ ]Yes [ ]No B. If the answer to A is NO: 1. How long have you lived there? 2. How long has it been on site? 3. Is the trailer permanently blocked and skirted? [ ]Yes [ ]No 4. When will the trailer be moved on site and where will the trailer be located on the site? Attach a drawing showing trailer location. C. How many bedrooms? 2. Is your home an existing home? [ ]Yes [ ]No Size of Home X. If you answer yes, please fill out section 2 A,B and skip down to Section 4. A. Has there been any home improvements in the last three years, such as additions to the home, bedroom(s), bathroom or complete newly installed plumbing throughout the home. B. How many bedrooms? 3. Is your home newly construction? [ ]Yes [ ]No If you answer yes, please fill out Section 3 A,B, & C.

5 A. When will the home be ready for occupancy? B. Where will the house be constructed on the site? Attach a drawing showing the house location. C. How many bedrooms? D. Is there Electric Service hook up to the home? [ ]Yes [ ]No If no, when will the electric service be provided? E. Mailing address of new home if different from above address: When will you start using the new mailing address? 4. Location of the house to be serviced. (Give complete accurate directions to the site from the Sault). 5. Is there an existing; [ ]Well [ ]Septic Tank/Drainfield [ ]Community Water System [ ]Community Sewer System 6. Describe the problems your having and with what: F. LAND INFORMATION: 1. Is your home site on [ ]Trust land [ ]Taxable Land [ ]Leased Land? 2. If you own the land what is the Tax Role Number: County Registered at: 3. Legal description of home site: 4. PROVIDE: A location map from the Plat book showing location of home site, and showing distances and directions from known paved arterial road. G. GENERAL INFORMATION: 1. Do you own any other house not occupied by your family? [ ]Yes [ ]No

6 If yes, state where the house is located and by whom it is occupied by: 2. Does any one in your family who is a permanent family member listed under Part B of this application have a severe health problem, handicap or permanent disabled? [ ]Yes [ ]No H. RELEASE OF INFORMATION: I understand that all information contained in this application is confidential. I hereby authorize the Sanitation Program permission to release any and all information contained in this application as needed to assist in the provision to services to my household. Said information may be released to potential vendors and any other person or agency deemed appropriate to assist the provision of services for the Sanitation Program. I. APPLICANT CERTIFICATION: I certify that all the answers given are true, complete and correct to the best of my knowledge and belief, and are made in good faith. I understand that if it is found that any information is false, I will not be considered for the Sanitation Program and my file will not be processed. Signature Spouse's Signature Date Date PAPER REDUCTION ACT STATEMENT This information is being collected to select eligible families/individuals to participate in the Sanitation Program. This information will be used to determine the eligibility of the applicants. Response to this request is required to obtain benefit. If you have any question or need help filling out this application, call (906) Mail completed application with attachments to: Sanitation Program 2218 Shunk Road Sault Ste. Marie, MI 49783