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Home
About
Our Board Members
Community Properties
Other Supports & Services
Pioneer Lodge & House
Gallery
Photos
Videos
Contact
Apply Now
Rent Assistance Benefit Application
APPLICATION FOR RENT ASSISTANCE
(CONFIDENTIAL)
NOTE: PLEASE ANSWER ALL QUESTIONS
1. Applicant’s Name
Last Name
First Name
Home Telephone
Business Telephone
Alberta Health Care No.
Email
2. Spouse's Name
Last Name
First Name
Alberta Health Care No.
3. Marital Status
Married
Widowed
Single
Divorced
Separated
Common-law
If Common-law or Separated, state how long
4. List all persons,
INCLUDING YOURSELF
, who will be living with you should your application be approved.
LAST NAME
FIRST NAME
RELATIONSHIP
TO APPLICANT
BIRTH DATE
DAY/MO/YR
OCCUPATION
SCHOOL GRADE
Is a baby expected?
No
Yes
If yes, give estimated due date
5. Are all members listed above Canadian Citizens
No
Yes
If no, provide copies of immigration papers for members who are not Canadian Citizens.
6. Present Address
7. Do you own or rent your present accommodation?
Own
Rent
Present rent or house payment is:
Per Month, Plus
For Heat
For Power
For Water and Sewer
8. If renting:
Landlord's Name
Landlord's Phone Number
Landlord's Address
9. Present accommodation is a:
House
Townhouse
Apartment
Rooming House
Motel/Hotel
Other
If other, please specify.
10. Number of rooms in present accommodation:
Kitchen
Kitchen
Living Room
Dining Room
Bathroom(s)
Bedroom(s)
11. Do you share any part of the accommodation with person(s) other than those listed above?
No
Yes
If yes, how many other people?
Adults
Children
What part of the accommodation is shared?
If you do not pay rent, do you contribute financially?
No
Yes
If yes, please specify.
12. Is any member of your family physically handicapped?
No
Yes
If yes, please specify.
13. STATEMENT OF INCOME
NOTE: ALL INFORMATION REGARDING YOUR FAMILY'S INCOME MUST BE COMPLETE AND ACCURATE. PROVIDE DETAILS OF CURRENT EMPLOYMENT HELD IN THE LAST TWELVE (12) MONTHS (BEGIN WITH THE MOST RECENT EMPLOYER).
Applicant
SIN
Employers
When did your spouse last work?
Co-Applicant or Spouse
SIN
Co-Applicant or Spouse's Employers
Other Household Member
SIN
Other Household Member's Employers
HAVE YOU RECEIVED ANY OTHER SOURCES OF INCOME IN THE PAST TWELVE (12) MONTHS? (PLEASE INDICATE IF NOT APPLICABLE) N/A
A. Student Grants/Allowance
B. Unemployment Insurance
C. Worker's Compensation
D. Social Assistance (Does not include Family Allowance)
E. Child Support/Alimony (Voluntary or Court Award)
F. Other Income (Tips, Interest, Royalties, etc.)
G. PENSIONS
1. Department Of Veterans Affairs
2. Old Age Security
3. Canada Pension (Retirement, Widow & Orphan Benefits)
4. Guaranteed Income Supplement
5. Alberta Income Supplement
6. Company Or Group Pension
H. Income From Self Employment
14. ASSETS
Cash on Hand
Cash in Bank Account
Stocks, Bonds, Mutual Funds, etc.
Real Estate
Mortgage(s)
Other Assets
NOTE: ESSENTIAL PERSONAL AND HOUSEHOLD EFFECTS SUCH AS CLOTHES, FURNITURE, VEHICLES, ETC. ARE NOT INCLUDED IN ASSETS.
15. Drivers Licence Number
Vehicle(s)
16. Please feel free to describe your present accommodation and any information you would like the Tenant Selection Committee to be aware of. This space is provided for you to explain your reasons for applying for Community Housing, and will assist us in the approval of your application.
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