Application - Supplemental Financials

SUPPLEMENTAL FINANCIAL INFORMATION FORM

FOR SUBSIDISED HOUSING

Please complete the supplemental financial information form below to provide us with the necessary information to determine if you qualify the Manor at Shalem, our Independent Subsidised Housing option. Please note that an application form must be completed for each individual seeking residency at Shalem.

Today's Date

Full Legal Name

All income will be verified if approved for a Subsidized Suite. Enter $0 if not applicable. *

	Enter $ Amount Per Month
Old Age Security & Guaranteed Income Supplement
Alberta Seniors Benefit
Disability Pension
Employment Income
AISH
Other
TOTAL

ASSETS

Please list any assets you may hold as well as their individual value. *

	Enter $ Amount Per Month
Asset 1
Asset 2
Asset 3
Asset 4
Asset 5
Asset 6
TOTAL

Additional Comments Regarding Assets

FINANCIAL OBLIGATIONS

Please list any debts and/ or other financial commitments you have. *

	Enter $ Amount Per Month
Financial Obligation 1
Financial Obligation 2
Financial Obligation 3
Financial Obligation 4
Financial Obligation 5
Financial Obligation 6
TOTAL

Please upload the following documents with your completed application below.

Upload Files Here

I acknowledge that the information in this supplemental application for subsidized housing is true to the best of my knowledge and is submitted in consideration for residency at Shalem Society for Senior Citizens Care.

Today's Date

Printed Name

Signature

Clear

Thank you for your interest in living at Shalem!

Please complete and click submit to send in your application.

If you have any questions please contact our Resident Life Administrator at living@shalem.ca or 403-240-2800 Ext.2

All shared information is kept private and confidential.

#101, 3010 - 51st Street SW | Calgary, Alberta | T3E 6V8

403.240.2800 | www.shalem.ca