INDIAN HOUSING PLAN

This form is for use by Tribes/TDHEs to identify the location of the
required elements of the Indian Housing Plan

Double-click the **Go** button to move to the section in order to enter
data.

  ------------------------ ------------------------------------ ------------------------------------------------------------------------------------------------------------ ----------------------
  **[Main                  **[Sub-Section]{.underline}**        **[Page]{.underline}**                                                                                       **[Go]{.underline}**
  Section]{.underline}**                                                                                                                                                     

  **Registration                                                [**2**](#general-information)                                                                                
  Information**                                                                                                                                                              

                                                                                                                                                                             

  **5-YEAR PLAN**                                               [**3**](#year-indian-housing-plan)                                                                           

  Mission Statement                                             [**3**](#please-enter-your-mission-statement-here)                                                           

  Goals and Objectives                                          [**4**](#please-enter-your-goals-and-objectives-here)                                                        

  Activities Plan                                               [**5**](#please-enter-your-activities-plan-here)                                                             

                                                                                                                                                                             

  **1-YEAR PLAN**                                               [**6**](#year-indian-housing-plan-1)                                                                         

  Goals and Objectives                                          [**6**](#please-enter-your-goals-and-objectives-here-1)                                                      

  Statement of Needs                                                                                                                                                         

                           The estimated low-income family      [**7**](#please-enter-your-low-income-housing-needs-here)                                                    
                           housing needs                                                                                                                                     

                           The estimated housing needs for all  [**8**](#please-enter-your-overall-housing-needs-here)                                                       
                           families                                                                                                                                          

  Financial Resources                                                                                                                                                        

                           Identification and description of    [**9**](#please-enter-your-identification-and-description-here)                                              
                           financial resources                                                                                                                               

                           Uses of such resources               [**10**](#please-enter-the-uses-of-such-resources-here)                                                      

  Affordable Housing                                                                                                                                                         
  Resources:                                                                                                                                                                 

                           The characteristics of the housing   [**11**](#please-enter-the-characteristics-of-the-housing-market-here)                                       
                           market                                                                                                                                            

                           The                                  [**12**](#please-enter-the-structurecoordinationcooperation-with-other-entities-here)                        
                           structure/coordination/cooperation                                                                                                                
                           with other entities                                                                                                                               

                           The manner in which housing needs    [**13**](#please-enter-the-manner-in-which-housing-needs-will-be-addressed-here)                             
                           will be addressed                                                                                                                                 

                           The manner in which 1937 Act housing [**14**](#please-enter-the-manner-in-which-1937-act-housing-will-be-protectedmaintained-here)                
                           will be protected/maintained                                                                                                                      

                           Existing/anticipated                 [**15**](#please-enter-your-existinganticipated-homeownershiprental-programs-here)                           
                           homeownership/rental programs                                                                                                                     

                           Existing/anticipated housing         [**16**](#please-enter-your-existinganticipated-housing-rehabilitation-programs-here)                        
                           rehabilitation programs                                                                                                                           

                           All other existing/anticipated       [**17**](#please-enter-other-existinganticipated-housing-assistance-here)                                    
                           housing assistance                                                                                                                                

                           Housing to be demolished or disposed [**18**](#please-enter-the-housing-to-be-demolished-or-disposed-of-here)                                     
                           of                                                                                                                                                

                           Coordination with tribal and State   [**19**](#please-enter-your-coordination-with-tribal-and-state-welfare-agencies-here)                        
                           welfare agencies                                                                                                                                  

                           The manner in which safety and       [**20**](#please-enter-the-manner-in-which-safety-and-resident-involvement-will-be-promoted-here)            
                           resident involvement will be                                                                                                                      
                           promoted                                                                                                                                          

                           Organizational capacity & key        [**21**](#please-enter-your-organizational-capacity-key-personnel-that-will-carry-out-ihp-activities-here)   
                           personnel that will carry out IHP                                                                                                                 
                           activities                                                                                                                                        

  Performance Objectives                                        [**22**](#please-enter-your-performance-objectives-here)                                                     

  Table 1 - Statement of                                        [23](#Table1Statement)                                                                                       
  Needs                                                                                                                                                                      

  Table 2 - Financial                                           [**25**](#table-2)                                                                                           
  Resources                                                                                                                                                                  

  Table 3 - Housing                                             [**27**](#table-3)                                                                                           
  Profile                                                                                                                                                                    

                                                                                                                                                                             

  **Other Submission                                            [**29**](#_Ref393107409)                                                                                     
  Items**                                                                                                                                                                    

                                                                                                                                                                             

  **Waiver Tracking**                                           [**31**](#WaiverTracking)                                                                                    

                                                                                                                                                                             

  **Environmental Review**                                      [**32**](#native-american-housing-assistance-and-self-determination-act)                                     

                                                                                                                                                                             

  **Standard Certification                                      [**33**](#native-american-housing-assistance-and-self-determination-act-1)                                   
  of Compliance**                                                                                                                                                            

                                                                                                                                                                             

  **Tribal Certification**                                      [**34**](#indian-housing-plan-tribal-certification)                                                          
  ------------------------ ------------------------------------ ------------------------------------------------------------------------------------------------------------ ----------------------

INDIAN HOUSING PLAN

### 

### [General Information:]{.underline}

Name of Tribe:

Tribal Chair: First Name: Last Name:

Telephone Number With Area Code: ( ) -

Tribe Street Address:

Tribe City:

Tribe State:

Tribe Zip:

Tribe Fax \# (if applicable): ( ) -

Tribal e-mail: userid@domain name

Name of TDHE (if applicable):

(Tribally Designated Housing Entity)

TDHE Contact Person: First Name: Last Name:

TDHE Phone Number With Area Code: ( ) -

TDHE Street Address:

TDHE City:

TDHE State:

TDHE Zip:

TDHE Fax \# (if applicable): ( ) -

**[Other Information:]{.underline}**

Federal Fiscal Year:

Recipient Fiscal Year End Date: 06/30/1997 (MM/DD/YYYY)

Grant Number: Estimated Grant Amount: Actual Grant Amount:

### 5-YEAR INDIAN HOUSING PLAN

The 5-Year Plan section of the Indian Housing Plan must contain, with
respect to the 5-year period beginning with the fiscal year for which
the plan is submitted, the following information:

1\. MISSION STATEMENT - A general statement of the mission of the Indian
tribe to serve the needs of the low-income families in the jurisdiction
of the Indian tribe, and outside the jurisdiction where tribal needs
require consideration, during the 5-year period.

###  Please enter your Mission Statement here:

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2\. GOALS AND OBJECTIVES - A statement of the goals and objectives of
the Indian tribe to enable the tribe to serve the needs identified in
the mission statement.

###  Please enter your Goals and Objectives here:

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3\. ACTIVITIES PLAN - An overview of the activities planned during the
period including an analysis of the manner in which the activities will
enable the tribe to meet its mission, goals, and objectives.

###  Please enter your Activities Plan here:

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### 1-YEAR INDIAN HOUSING PLAN

The 1-Year Plan section of the Indian Housing Plan must contain
information, relating to the upcoming fiscal year for which assistance
is to be made available, including the following:

1\. GOALS AND OBJECTIVES - A statement of the goals and objectives to be
accomplished during the period that are measurable as determined by the
Tribe/TDHE.

###  Please enter your Goals and Objectives here:

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2\. STATEMENT OF NEEDS - A statement of the housing needs of the
low-income Indian families residing in the jurisdiction of the Indian
tribe, and outside the jurisdiction where tribal needs require
consideration, and the means by which such needs will be addressed
during the

1-year period, including a description of:

a\. the estimated housing needs and the need for assistance for the
low-income Indian families in the jurisdiction, and outside the
jurisdiction where tribal needs require consideration, including a
description of the manner in which the geographical distribution of
assistance is consistent with the geographical needs and needs for
various categories of housing assistance; and

###  Please enter your Low-income Housing Needs here: 

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b\. the estimated housing needs for all Indian families in the
jurisdiction.

###  Please enter your Overall Housing Needs here:

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3\. FINANCIAL RESOURCES- An operating budget for the recipient, in a
form prescribed by the Secretary, including:

a\. an identification and a description of the financial resources
reasonably available to the recipient to carry out the purposes of
NAHASDA, including an explanation of the manner in which amounts made
available will leverage additional resources; and

###  Please enter your Identification and Description here:

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b\. the uses to which such resources will be committed, including
eligible and required affordable housing activities under title II of
NAHASDA and administrative expenses.

###  Please enter the Uses of Such Resources here:

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4\. AFFORDABLE HOUSING RESOURCES- A statement of the affordable housing
resources currently available and to be made available during the
period, including a description of:

a\. the significant characteristics of the housing market in the
jurisdiction, including the availability of housing from other public
sources, private market housing, and the manner in which such
characteristics influence the decision of the recipient to use grant
amounts to be provided under this Act for rental assistance, production
of new units, acquisition of existing units, or rehabilitation of units;

###  Please enter the characteristics of the housing market here:

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b\. the structure, coordination, and means of cooperation between the
recipient and any other governmental entities in the development,
submission, or implementation of housing plans, including a description
of the involvement of private, public, and nonprofit organizations and
institutions, and the use of loan guarantees under section 184 of the
Housing and Community Development Act of 1992, and other housing
assistance provided by the Federal Government for Indian tribes,
including loans, grants, and mortgage insurance;

### Please enter the structure/coordination/cooperation with other entities here:

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c\. the manner in which the plan will address the needs identified
pursuant to the Statement of Needs Section in paragraph 2;

###  Please enter the manner in which housing needs will be addressed here: 

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d\. the manner in which the recipient will protect and maintain the
viability of housing owned and operated by the recipient that was
developed under a contract between the Secretary and an Indian housing
authority pursuant to the United States Housing Act of 1937;

###  Please enter the manner in which 1937 Act housing will be protected/maintained here: 

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e\. any existing and anticipated homeownership programs and rental
programs to be carried out during the period, and the requirements and
assistance available under such programs;

###  Please enter your Existing/anticipated homeownership/rental programs here: 

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f\. any existing and anticipated housing rehabilitation programs
necessary to ensure the long-term viability of the housing to be carried
out during the period, and the requirements and assistance available
under such programs;

###  Please enter your Existing/anticipated housing rehabilitation programs here: 

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g\. all other existing or anticipated housing assistance provided by the
recipient during the period, including transitional housing, homeless
housing, college housing, supportive services housing, and the
requirements and assistance available under such programs;

###  Please enter other existing/anticipated housing assistance here: 

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h\. any housing to be demolished or disposed of, a timetable for such
demolition or disposition, and any other information required by the
Secretary with respect to such demolition or disposition;

###  Please enter the Housing to be demolished or disposed of here: 

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i\. the manner in which the recipient will coordinate with tribal and
State welfare agencies to ensure that residents of such housing will be
provided with access to resources to assist in obtaining employment and
achieving self-sufficiency;

###  Please enter your Coordination with tribal and State welfare agencies here: 

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j\. the requirements established by the recipient to promote the safety
of residents of such housing, facilitate the undertaking of crime
prevention measures, allow resident input and involvement, including the
establishment of resident organizations, and allow for the coordination
of crime prevention activities between the recipient and tribal and
local law enforcement officials; and

###  Please enter the manner in which safety and resident involvement will be promoted here: 

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k\. the entity that will carry out the activities under the plan,
including the organizational capacity and key personnel of the entity.

###  Please enter your Organizational capacity & key personnel that will carry out IHP activities here: 

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5\. PERFORMANCE OBJECTIVES In accordance with 24 CFR 1000.504,
performance objectives are to be developed by each recipient and
included in this 1-year plan. Performance objectives are criteria by
which the recipient will monitor and evaluate its performance; provide
quantitative measurements by which the recipient will gauge its
performance; and determine the impact and benefit the grant beneficiary
derives from the accomplishments obtained under the plan. For example,
if in the IHP, the recipient indicates it will build new houses, the
performance objective may be the completion of the homes within a
certain time period and within a certain budgeted amount, and measure
the number of tribal members and families served.

###  Please enter your Performance Objectives here: 

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### TABLE 1

[]{#Table1Statement .anchor}**STATEMENT OF NEEDS**

  ----------------------------- -----------------------------------------
  Name of Tribe:                

  Name of TDHE (if applicable): 

  Federal Fiscal Year:          
  ----------------------------- -----------------------------------------

Tribal/TDHE Program Year:

Indian Area

(Double-Click button to return to top)

+-----------+-----------+----------+----------+----------+---+-----------+
| PART I:   |           |          |          |          |   |           |
| INDIAN    |           |          |          |          |   |           |
| AR        |           |          |          |          |   |           |
| EA/TRIBAL |           |          |          |          |   |           |
| PROFILE   |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| **Person  |           | **All    |          |          |   |           |
| and       |           | I        |          |          |   |           |
| Family    |           | ndians** |          |          |   |           |
| Cat       |           |          |          |          |   |           |
| egories** |           | **in the |          |          |   |           |
|           |           | Indian   |          |          |   |           |
|           |           | Area**   |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
|           |           | **All    | **Low-   |          |   |           |
|           |           | Income   | Income** |          |   |           |
|           |           | Levels** |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| column a  |           | column b | column c |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| 1\. Total |           |          |          |          |   |           |
| Indian    |           |          |          |          |   |           |
| P         |           |          |          |          |   |           |
| opulation |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| 2\.       |           |          |          |          |   |           |
| Number of |           |          |          |          |   |           |
| Indian    |           |          |          |          |   |           |
| Families  |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| 3\.       |           |          |          |          |   |           |
| Number of |           |          |          |          |   |           |
| Elderly   |           |          |          |          |   |           |
| Indian    |           |          |          |          |   |           |
| Families  |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| 4\.       |           |          |          |          |   |           |
| Number of |           |          |          |          |   |           |
| Nea       |           |          |          |          |   |           |
| r-Elderly |           |          |          |          |   |           |
| Indian    |           |          |          |          |   |           |
| Families  |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| 5\.       |           |          |          |          |   |           |
| Number of |           |          |          |          |   |           |
| Indian    |           |          |          |          |   |           |
| Families  |           |          |          |          |   |           |
| Living in |           |          |          |          |   |           |
| Su        |           |          |          |          |   |           |
| bstandard |           |          |          |          |   |           |
| Housing   |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| 6\.       |           |          |          |          |   |           |
| Number of |           |          |          |          |   |           |
| Indian    |           |          |          |          |   |           |
| Families  |           |          |          |          |   |           |
| Living in |           |          |          |          |   |           |
| Ove       |           |          |          |          |   |           |
| r-Crowded |           |          |          |          |   |           |
| C         |           |          |          |          |   |           |
| onditions |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| PART II:  |           |          |          |          |   |           |
| OTHER     |           |          |          |          |   |           |
| INDIAN    |           |          |          |          |   |           |
| AR        |           |          |          |          |   |           |
| EA/TRIBAL |           |          |          |          |   |           |
| PROFILE   |           |          |          |          |   |           |
| (         |           |          |          |          |   |           |
| OPTIONAL) |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| **Person  |           | **All    | **Low-   |          |   |           |
| and       |           | Income   | Income** |          |   |           |
| Family    |           | Levels** |          |          |   |           |
| Cat       |           |          |          |          |   |           |
| egories** |           |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
| 7\.       | a\.       |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
|           | b\.       |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
|           | c\.       |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
|           | d\.       |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+
|           | e\.       |          |          |          |   |           |
+-----------+-----------+----------+----------+----------+---+-----------+

Table 1 Statement of Needs continued

+---------------+---+--------------+---------+-----------+----------------+
| PART III:     |   |              |         |           |                |
| CURRENT       |   |              |         |           |                |
| STATUS AND    |   |              |         |           |                |
| FUTURE NEEDS  |   |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| **Type of     |   |              | **E     | **Unmet   | **Unmet Needs  |
| Housing**     |   |              | xisting | Needs for | for Low-Income |
|               |   |              | Ho      | All       | Indian         |
|               |   |              | using** | Indian    | Families**     |
|               |   |              |         | F         |                |
|               |   |              |         | amilies** |                |
+---------------+---+--------------+---------+-----------+----------------+
| column a      |   |              | column  | column c  | column d       |
|               |   |              | b       |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| 8\. Rental    | a |              |         |           |                |
|               | \ |              |         |           |                |
| Housing       | . |              |         |           |                |
|               | N |              |         |           |                |
|               | u |              |         |           |                |
|               | m |              |         |           |                |
|               | b |              |         |           |                |
|               | e |              |         |           |                |
|               | r |              |         |           |                |
|               | o |              |         |           |                |
|               | f |              |         |           |                |
|               | U |              |         |           |                |
|               | n |              |         |           |                |
|               | i |              |         |           |                |
|               | t |              |         |           |                |
|               | s |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
|               | b |              |         |           |                |
|               | \ |              |         |           |                |
|               | . |              |         |           |                |
|               | N |              |         |           |                |
|               | u |              |         |           |                |
|               | m |              |         |           |                |
|               | b |              |         |           |                |
|               | e |              |         |           |                |
|               | r |              |         |           |                |
|               | o |              |         |           |                |
|               | f |              |         |           |                |
|               | U |              |         |           |                |
|               | n |              |         |           |                |
|               | i |              |         |           |                |
|               | t |              |         |           |                |
|               | s |              |         |           |                |
|               | N |              |         |           |                |
|               | e |              |         |           |                |
|               | e |              |         |           |                |
|               | d |              |         |           |                |
|               | i |              |         |           |                |
|               | n |              |         |           |                |
|               | g |              |         |           |                |
|               | R |              |         |           |                |
|               | e |              |         |           |                |
|               | h |              |         |           |                |
|               | a |              |         |           |                |
|               | b |              |         |           |                |
|               | i |              |         |           |                |
|               | l |              |         |           |                |
|               | i |              |         |           |                |
|               | t |              |         |           |                |
|               | a |              |         |           |                |
|               | t |              |         |           |                |
|               | i |              |         |           |                |
|               | o |              |         |           |                |
|               | n |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| 9\. Homeowner | a |              |         |           |                |
| Housing       | \ |              |         |           |                |
|               | . |              |         |           |                |
|               | N |              |         |           |                |
|               | u |              |         |           |                |
|               | m |              |         |           |                |
|               | b |              |         |           |                |
|               | e |              |         |           |                |
|               | r |              |         |           |                |
|               | o |              |         |           |                |
|               | f |              |         |           |                |
|               | U |              |         |           |                |
|               | n |              |         |           |                |
|               | i |              |         |           |                |
|               | t |              |         |           |                |
|               | s |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
|               | b |              |         |           |                |
|               | \ |              |         |           |                |
|               | . |              |         |           |                |
|               | N |              |         |           |                |
|               | u |              |         |           |                |
|               | m |              |         |           |                |
|               | b |              |         |           |                |
|               | e |              |         |           |                |
|               | r |              |         |           |                |
|               | o |              |         |           |                |
|               | f |              |         |           |                |
|               | U |              |         |           |                |
|               | n |              |         |           |                |
|               | i |              |         |           |                |
|               | t |              |         |           |                |
|               | s |              |         |           |                |
|               | N |              |         |           |                |
|               | e |              |         |           |                |
|               | e |              |         |           |                |
|               | d |              |         |           |                |
|               | i |              |         |           |                |
|               | n |              |         |           |                |
|               | g |              |         |           |                |
|               | R |              |         |           |                |
|               | e |              |         |           |                |
|               | h |              |         |           |                |
|               | a |              |         |           |                |
|               | b |              |         |           |                |
|               | i |              |         |           |                |
|               | l |              |         |           |                |
|               | i |              |         |           |                |
|               | t |              |         |           |                |
|               | a |              |         |           |                |
|               | t |              |         |           |                |
|               | i |              |         |           |                |
|               | o |              |         |           |                |
|               | n |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| 10\.          |   |              |         |           |                |
| Supportive    |   |              |         |           |                |
| Service       |   |              |         |           |                |
| Housing (# of |   |              |         |           |                |
| units)        |   |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| 11\. College  |   |              |         |           |                |
| Housing (# of |   |              |         |           |                |
| units)        |   |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| 12\.          |   |              |         |           |                |
| Transitional  |   |              |         |           |                |
| Housing (# of |   |              |         |           |                |
| units)        |   |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| 13\. Homeless |   |              |         |           |                |
| Housing (# of |   |              |         |           |                |
| beds)         |   |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| PART IV:      |   |              |         |           |                |
| OTHER CURRENT |   |              |         |           |                |
| STATUS AND    |   |              |         |           |                |
| FUTURE NEEDS  |   |              |         |           |                |
| (OPTIONAL)    |   |              |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
| 14\.          |   | a\.          |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
|               |   | b\.          |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
|               |   | c\.          |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
|               |   | d\.          |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+
|               |   | e\.          |         |           |                |
+---------------+---+--------------+---------+-----------+----------------+

Data Source:

### TABLE 2

**FINANCIAL RESOURCES**

  --------------------------- -------------------------------------------
  Name of Tribe:              

  Name of TDHE (if            
  applicable):                

  Federal Fiscal Year:        

  Tribal/TDHE Program Year:   
  --------------------------- -------------------------------------------

(Double-Click button to return to top)

+--------------------------------------------------+-------------------+
| PART I: SOURCES OF FUNDS FOR NAHASDA ACTIVITIES  |                   |
+--------------------------------------------------+-------------------+
| **Sources of Funds**                             | **Planned         |
|                                                  | Amount**          |
+--------------------------------------------------+-------------------+
| column a                                         | column b          |
+--------------------------------------------------+-------------------+
| 1\. HUD Resources                                |                   |
+--------------------------------------------------+-------------------+
| > a\. NAHASDA Block Grant                        |                   |
+--------------------------------------------------+-------------------+
| > b\. NAHASDA Program Income                     |                   |
+--------------------------------------------------+-------------------+
| > c\. NAHASDA Title VI                           |                   |
+--------------------------------------------------+-------------------+
| > d\. Section 184 Loan Guarantee                 |                   |
+--------------------------------------------------+-------------------+
| > e\. Indian Community Development Block Grant   |                   |
+--------------------------------------------------+-------------------+
| > f\. Drug Elimination Grants and Drug Technical |                   |
| > Assistance                                     |                   |
+--------------------------------------------------+-------------------+
| > g\. Prior Year Funds                           |                   |
+--------------------------------------------------+-------------------+
| > h\. Other                                      |                   |
+--------------------------------------------------+-------------------+
| 2\. Existing Program Resources                   |                   |
+--------------------------------------------------+-------------------+
| > a\. 1937 Housing Act Programs                  |                   |
+--------------------------------------------------+-------------------+
| > b\. Other HUD Programs                         |                   |
+--------------------------------------------------+-------------------+
| 3\. Other Federal or State Resources             |                   |
+--------------------------------------------------+-------------------+
| > a\. BIA Home Improvement Program               |                   |
+--------------------------------------------------+-------------------+
| > b\. Other                                      |                   |
+--------------------------------------------------+-------------------+
| 4\. Private Resources                            |                   |
+--------------------------------------------------+-------------------+
| > a\. Tribal Contributions for affordable        |                   |
| > housing                                        |                   |
+--------------------------------------------------+-------------------+
| > b\. Financial Institution                      |                   |
+--------------------------------------------------+-------------------+
| > c\. Other                                      |                   |
+--------------------------------------------------+-------------------+
| 5\. Other                                        |                   |
+--------------------------------------------------+-------------------+
| 6\. Total Resources                              |                   |
+--------------------------------------------------+-------------------+

Table 2 Financial Resources Continued

  ---------------- ------------------ ------------- ------------ -------------
  PART II:                                                       
  ALLOCATION OF                                                  
  FUNDS FOR                                                      
  NAHASDA                                                        
  ACTIVITIES                                                     

  **Activity**                        **Planned**                

                                      **Budgeted    **Number of  **Number of
                                      Amount**      Units**      Families**

  column a                            column b      column c     column d

  7\. Indian                                                     
  Housing                                                        
  Assistance                                                     

  a\.                                                            
  Modernization                                                  
  (1937 Housing                                                  
  Act)                                                           

  b\. Operating                                                  
  (1937 Housing                                                  
  Act)                                                           

  8\. Development                                                

  a\. Rental       1\. Construction                              
                   of new units                                  

                   2\. Acquisition                               

                   3\. Rehabilitation                            

  b\.              1\. Construction                              
  Homeownership    of new units                                  

                   2\. Acquisition                               

                   3\. Rehabilitation                            

  9\. Housing                                                    
  Services                                                       

  10\. Housing                                                   
  Management                                                     
  Services                                                       

  11\. Crime                                                     
  Prevention and                                                 
  Safety                                                         

  12\. Model                                                     
  Activities                                                     
  (specify below)                                                

  a\.                                                            

  13\. Planning                                                  
  and                                                            
  Administration                                                 

  14\. Reserves                                                  

  15\. Other                                                     

  16\. Total                                                     
  ---------------- ------------------ ------------- ------------ -------------

###  TABLE 3

**HOUSING PROFILE**

  -------------------------- --------------------------------------------
  Name of Tribe:             

  Name of TDHE (if           
  applicable):               

  Federal Fiscal Year:       

  Tribal/TDHE Program Year:  
  -------------------------- --------------------------------------------

(Double-Click button to return to top)

+-------------------+------------------+---------------+---------------+
| **PART I: 1937    |                  |               |               |
| HOUSING ACT       |                  |               |               |
| INVENTORY UNDER   |                  |               |               |
| MANAGEMENT**      |                  |               |               |
+-------------------+------------------+---------------+---------------+
| **Housing         |                  | **Number of   | **Number of   |
| Inventory**       |                  | Units         | Units**       |
|                   |                  | (Subtotal)**  |               |
|                   |                  |               | **(Total)**   |
+-------------------+------------------+---------------+---------------+
| column a          |                  | column b      | column c      |
+-------------------+------------------+---------------+---------------+
| 1\. Mutual Help   |                  |               |               |
| Units Under       |                  |               |               |
| Management as of  |                  |               |               |
| September 30      |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 2\. Low Rent      |                  |               |               |
| Units Under       |                  |               |               |
| Management as of  |                  |               |               |
| September 30      |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 3\. Turnkey III   |                  |               |               |
| Units Under       |                  |               |               |
| Management as of  |                  |               |               |
| September 30      |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 4\. Total         |                  |               |               |
| Beginning 1937    |                  |               |               |
| Housing Act       |                  |               |               |
| Inventory         |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 5\. Units Planned | a\. Mutual Help  |               |               |
| to be Demolished  |                  |               |               |
| or Disposed of    |                  |               |               |
| During Plan       |                  |               |               |
| Period            |                  |               |               |
+-------------------+------------------+---------------+---------------+
|                   | b\. Low Rent     |               |               |
+-------------------+------------------+---------------+---------------+
|                   | c\. Turnkey III  |               |               |
+-------------------+------------------+---------------+---------------+
|                   | d\. Total        |               |               |
+-------------------+------------------+---------------+---------------+
| 6\. Units Planned | a\. Mutual Help  |               |               |
| to be Conveyed    |                  |               |               |
| During Plan       |                  |               |               |
| Period            |                  |               |               |
+-------------------+------------------+---------------+---------------+
|                   | b\. Low Rent     |               |               |
+-------------------+------------------+---------------+---------------+
|                   | c\. Turnkey III  |               |               |
+-------------------+------------------+---------------+---------------+
|                   | d\. Total        |               |               |
+-------------------+------------------+---------------+---------------+
| 7\. Total Planned |                  |               |               |
| Ending 1937       |                  |               |               |
| Housing Act       |                  |               |               |
| Inventory as of   |                  |               |               |
| September 30      |                  |               |               |
+-------------------+------------------+---------------+---------------+
| **PART II: 1937   |                  |               |               |
| HOUSING ACT       |                  |               |               |
| INVENTORY IN THE  |                  |               |               |
| DEVELOPMENT       |                  |               |               |
| PIPELINE**        |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 8\. Mutual Help   |                  |               |               |
| Units in the      |                  |               |               |
| Pipeline as of    |                  |               |               |
| September 30      |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 9\. Low Rent      |                  |               |               |
| Units in the      |                  |               |               |
| Pipeline as of    |                  |               |               |
| September 30      |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 10\. Total Units  |                  |               |               |
| in Pipeline as of |                  |               |               |
| September 30      |                  |               |               |
+-------------------+------------------+---------------+---------------+
| **PART III:       |                  |               |               |
| SECTION 8         |                  |               |               |
| VOUCHERS AND      |                  |               |               |
| CERTIFICATES**    |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 11\. Section 8    |                  |               |               |
| Vouchers and      |                  |               |               |
| Certificates as   |                  |               |               |
| of September 30   |                  |               |               |
+-------------------+------------------+---------------+---------------+
| **PART IV:        |                  |               |               |
| NAHASDA UNITS**   |                  |               |               |
+-------------------+------------------+---------------+---------------+
| 12\. Total        |                  |               |               |
| NAHASDA Units as  |                  |               |               |
| of September 30   |                  |               |               |
+-------------------+------------------+---------------+---------------+

### OTHER SUBMISSIONS

Recipients of NAHASDA funds are required to prepare and submit the
following information:

1\. Useful Life

Sections 205(a)(2) and 209 of NAHASDA requires that housing remain
affordable. Each recipient will determine the \"useful life\" period for
its units. The useful life of each assisted housing unit in each
development must be described. This information may be described here or
in the affordable housing resources section of the 1-year plan.

###  Please enter your Useful Life Information: 

2\. Model Housing Activities

Recipients are required to submit proposals to operate model housing
activities or other housing programs as defined in NAHASDA sections
201(b)(2) and 202(6) for non low-income families. If a model housing
activity is to be undertaken during the 1-year plan period, proposals
may be included here, in the affordable housing resources section of the
1-year plan, or as a separate submission. All proposals must be approved
by the Secretary prior to beginning any model housing activity.

###  Please enter your Model Housing Activities here: 

3\. Tribal and other Indian Preference

Section 201(b)(4) of NAHASDA allows preference for tribal members and
other Indian families. If preference will be given to tribal members or
other Indian families, the preference policy must be described. This
information may be provided here or in the affordable housing resources
section of the 1-year plan.

### Please enter your preference policy here: 

**4. Planning and Administration**

In accordance with the Final Rule, state the percentage of annual grant
funds which will be used for planning and administrative purposes. If
the amount is over 20 percent of the annual grant amount, HUD approval
is required.

###  Please enter your planning and administration here: 

**5. Minimal Funding**

As stated in the Final Rule, the first year of NAHASDA participation, a
tribe whose allocation is less than \$50,000 under the need component of
the formula shall have its need component of the grant adjusted to
\$50,000. Certify here that there is a need for funding.

### Please enter your minimal funding here: 

**6. Method of Payment**

In accordance with the Final Rule, state the method of payment the
tribe/THDE will use to request its grant funds.

###  Please enter your method of payment here: 

(Double-Click button to return to top)

[]{#WaiverTracking .anchor}**WAIVER REQUESTS**

**Please indicate here if you have bet the regulatroy requirements for a
waiver of a section and request a waiver for that section.**

###  Please enter your Waiver Request Comments here:

(Double-Click button to return to top)

  ------------------------ ------------------------------------------ -------------------------
  **[Main                  **[Sub-Section]{.underline}**              **[Waiver
  Section]{.underline}**                                              Request?]{.underline}**

  **5-YEAR PLAN**                                                     

  Mission Statement                                                   **No**

  Goals and Objectives                                                **No**

  Activities Plan                                                     **No**

  **1-YEAR PLAN**                                                     

  Goals and Objectives                                                **No**

  Statement of Needs                                                  

                           The estimated low-income family housing    **No**
                           needs                                      

                           The estimated housing needs for all        **No**
                           families                                   

  Financial Resources                                                 

                           Identification and description of          **No**
                           financial resources                        

                           Uses of such resources                     **No**

  Affordable Housing                                                  
  Resources:                                                          

                           The characteristics of the housing market  **No**

                           The structure/coordination/cooperation     **No**
                           with other entities                        

                           The manner in which housing needs will be  **No**
                           addressed                                  

                           The manner in which 1937 Act housing will  **No**
                           be protected/ maintained                   

                           Existing/anticipated homeownership/rental  **No**
                           programs                                   

                           Existing/anticipated housing               **No**
                           rehabilitation programs                    

                           All other existing/anticipated housing     **No**
                           assistance                                 

                           Housing to be demolished or disposed of    **No**

                           Coordination with tribal and State welfare **No**
                           agencies                                   

                           The manner in which safety and resident    **No**
                           involvement will be promoted               

                           Organizational capacity & key personnel    **No**
                           that will carry out IHP activities         

  Performance Objectives                                              **No**

  Table 1 - Statement of                                              **No**
  Needs                                                               

  Table 2 - Financial                                                 **No**
  Resources                                                           

  Table 3 - Housing                                                   **No**
  Profile                                                             
  ------------------------ ------------------------------------------ -------------------------

###   {#section-1 .unnumbered}

### NATIVE AMERICAN HOUSING ASSISTANCE AND SELF-DETERMINATION ACT 

**ENVIRONMENTAL REVIEW - EXPRESSION OF INTENT**

*To facilitate the completion of environmental review responsibilities
under the Indian Housing Block Grant program, this Expression of Intent
will provide HUD with information needed to assist the tribe in
completion of these activities and to schedule resources needed to
complete environmental review responsibilities. Environmental reviews
are completed for individual activities included in the Indian Housing
Plan. The tribe can choose to complete the environmental review for some
or all activities and can decide at a later date to change its
decision.*

**No** The tribe plans to assume the status of a Federal official under
the National Environmental Policy Act of 1969 and the other provisions
of law listed in 24 CFR 58.5 insofar as the provisions of the Act and
such other provisions of law apply to the Indian tribe\'s proposed
program pursuant to 24 CFR part 58.

**No** The tribe plans to request HUD to fulfill environmental review
responsibilities stated above pursuant to 24 CFR part 50.

**No** The tribe plans to work with HUD and provide information and
studies to HUD to allow HUD to fulfill environmental review
responsibilities stated above pursuant to 24 CFR part 50.

**No** The tribe plans to assume the responsibilities stated above
except for the following listed activities for which it will request HUD
to fulfill the environmental review responsibilities.

###   {#section-2 .unnumbered}

### NATIVE AMERICAN HOUSING ASSISTANCE AND SELF-DETERMINATION ACT 

**INDIAN HOUSING PLAN CERTIFICATION OF COMPLIANCE**

*This certification is for use with the Indian Housing Plan (IHP). If
the IHP is prepared and submitted by a Tribally Designated Housing
Entity on behalf of a tribe, it must be accompanied by a tribal
certification from the recognized tribal government covered under the
IHP. In accordance with the applicable statutes, the recipient certifies
that:.*

In accordance with the applicable statutes, the recipient certifies
that:

**No** (A) it will comply with title II of the Civil Rights Act of 1968
in carrying out this Act, to the extent that such title is applicable,
and other applicable Federal statutes;

The following certifications will only apply where applicable based on
program activities

**No** (B) it will maintain adequate insurance coverage for housing
units that are owned and operated or assisted with grant amounts
provided under the Native American Housing and Self-Determination Act of
1996 (the Act), in compliance with such requirements as may be
established by the Secretary;

**No** (C) policies are in effect and are available for review by the
Secretary and the public governing the eligibility, admission, and
occupancy of families for housing assisted with grant amounts provided
under the Act;

**No** (D) policies are in effect and are available for review by the
Secretary and the public governing rents charged, including the methods
by which such rents or homebuyer payments are determined, for housing
assisted with grant amounts provided under the Act; and

**No** (E) policies are in effect and are available for review by the
Secretary and the public governing the management and maintenance of
housing assisted with grant amounts provided under the Act.

No Authorized Official Certification To Above Information Date:
(MM/DD/YYYY)

Authorized Official's Title:

**NATIVE AMERICAN HOUSING ASSISTANCE AND SELF-DETERMINATION ACT**

### INDIAN HOUSING PLAN TRIBAL CERTIFICATION

*This certification is for use with the Indian Housing Plan (IHP) when a
Tribally Designated Housing Entity (TDHE) prepares the IHP on behalf of
an Indian tribe. This certification must be executed by the recognized
tribal government covered under the IHP.*

The recognized tribal government of the grant beneficiary certifies
that:

**No** (1) it had an opportunity to review the IHP and has authorized
the submission of the IHP by the housing entity; or

**No** (2) it has delegated to such TDHE the authority to submit an IHP
and amendments on behalf of the tribe without prior review by the tribe.

No Authorized Official Certification To Above Information Date:
(MM/DD/YYYY)

Authorized Official's Title: