Rimoka Housing - Community Housing and Rent Assistance Benefit

INSTRUCTIONS FOR COMPLETING APPLICATION:

Applications will not be processed unless all documentation is provided and all questions are fully answered. If a question does not apply to your situation, mark N/A in the section. Space is provided for any other information of which you would like us to be aware of.

You will be required to provide the following:

Photo ID

Alberta Health Care cards for yourself and your dependents

A signed lease agreement and three-most recent month’s rent receipts

A signed letter from the employer of EACH working member in your family stating the rate of pay, number of hours worked per week, total earnings, and commencement date of current employment. Also a copy of your TWO most recent pay cheques.

If you or any member of your family is receiving Employment Insurance, Worker’s
Compensation or Social Assistance, a letter from the appropriate official must be attached verifying the amount of the benefit.

Documentation to verify all other sources of income (i.e. child support, oil royalties, etc.) by a bank statement, benefit cheque, pension cheque, etc
If you are a student, a letter from the registrar of your school verifying your registration as a full-time or part-time student and all funding documents. This is required for household head, co-applicant and all dependents over the age of 18.
A current Tax return, Notice of Assessment, Child Tax Credit and GST rebate.

Your application shall be held for two weeks to allow you time to obtain the information we require.

After two (2) weeks, if the required information is not received, your application will be cancelled.

It is your responsibility to contact this office to report in writing any changes in your circumstances that affect your application.
Your application shall be held for two weeks to allow you time to obtain the information we require.

After two (2) weeks, if the required information is not received, your application will be cancelled.

It is your responsibility to contact this office to report in writing any changes in your circumstances that affect your application.

APPLICATION FORM - Community Housing and Direct Rent Supplement

CONFIDENTIAL please read carefully
Indicate which program you are applying for:

Community HousingDirect Rent Supplement
I understand that this application does not constitute an agreement on the part of
RIMOKA HOUSING FOUNDATION, or its agents, to provide me with rental accommodation.

I further acknowledge the right of RIMOKA HOUSING FOUNDATION, or its agents at any time prior to the execution and delivery to me of a lease hereby applied for, to withdraw, revoke or cancel, without penalty or liability for damages or otherwise, any acceptance or approval of this application previously made or given.

I hereby authorize RIMOKA HOUSING FOUNDATION, or its agents, to investigate any or all of the statements made herein, being fully aware that discovery of any false statement shall cancel any further consideration of my application.

I further agree that I am obligated to advise RIMOKA HOUSING FOUNDATION or its
agents, in writing, of any changes in family composition, gross family income, assets, employment, or change of address, should they occur.

I further agree the information provided by me pertains to all persons named within this application.

I further agree to give permission for current or past landlords and employers to release any information which directly affects this application for subsidized housing.
Signature of Applicant

Clear
Signature of Co-Applicant

Clear

ASSETS:

Please list the total value of all assets and investments as well as interest or income from investments. Provide statements and tax slips for verification.

	Dollar Value
Cash
Bank Accounts
Stocks, Bonds, Mutual Funds
RRSP, RRIF, Tax Free Savings Accounts
Other Assets (ie: RV, ATV, boat, camper, tools, etc)
Real Estate
Mortgage
Vehicle - Provide—Year/Make/Model
Vehicle - Provide—Year/Make/Model

NOTE: Essential personal and household effects such as clothes, furniture, etc. are not included in assets.

STATEMENT OF INCOME:All information regarding your family’s income must be complete and accurate. Include details of allemployment held over the last twelve (12) months.
Applicant's Name

First NameLast Name

	Address	Date of Employment (To/From)	Gross Monthly Pay'	Hourly Rate	Hours Per Week
Company Name 1
Company Name 2
Company Name 3

Co-Applicant's Name

First NameLast Name

	Address	Date of Employment (To/From)	Gross Monthly Pay'	Hourly Rate	Hours Per Week
Company Name 1
Company Name 2
Company Name 3

Other Household Member

First NameLast Name

	Address	Date of Employment (To/From)	Gross Monthly Pay'	Hourly Rate	Hours Per Week
Company Name 1
Company Name 2
Company Name 3

Other Income

Have you received any other sources of income in the past twelve (12) months?

Source of Income

	Name of Family Mamber in Receipt	Start Date	End Date	Gross Monthly Income
Student Grants/Allowances
Employment Insurance
Worker’s Compensation
Income Support Benefits
AISH
Child Support/Alimony
Child Tax Credit
Other Income (tips, interest, treaty benefits, royalties, etc)
CPP Disability
Pensions
A. Old Age Security
B. Guaranteed Income Support
C. CPP (retirement, widow, orphan)
D. Alberta Seniors Benefits
E. Veteran’s Affairs
F. Private Pension
G. Other
11. Income from Self Employment

**Details of self-employment must be outlined by the submission of a financial statement subject to review by the Housing Authority.

This information is being collected for the purpose of the application process. All information collectedfor this purpose will be kept confidential as per the Freedom of Information and Protection of Privacy Act.

FOR APPLICANT’S USE
Other related information you wish to provide. Attach a separate sheet is more space is needed.
This application will not be processed, unless all questions are fully answered,most recent tax year’s notice of assessment is included, and is signed by acommissioner for oaths.
APPLICANTS WILL BE SEEN BY APPOINTMENT ONLY
Applications will be kept on file for one year. If you wish to remain on the waitlistyou MUST re-apply prior to the one year, or you will be removedfrom the waitlist.
Should be Empty:

	Last Name	First Name	Relationship to Applicant	Birth Date Month/Day/Year	Occupation or School Grade
1
2
3
4
5

	Previous Landlord's Name	Address	Phone Number	Length of Tenancy	Monthly Payment	Reason for Leaving
Landlord 1
Landlord 2
Landlord 3
Landlord 4
Landlord 5

APPLICATION FORM - Community Housing and Direct Rent Supplement(CONFIDENTIAL PLEASE READ CAREFULLLY)

ASSETS:

NOTE: Essential personal and household effects such as clothes, furniture, etc. are not included in assets.

Other Income

**Details of self-employment must be outlined by the submission of a financial statement subject to review by the Housing Authority.

FOR APPLICANT’S USE

This application will not be processed, unless all questions are fully answered,most recent tax year’s notice of assessment is included, and is signed by acommissioner for oaths.

APPLICANTS WILL BE SEEN BY APPOINTMENT ONLY

Applications will be kept on file for one year. If you wish to remain on the waitlistyou MUST re-apply prior to the one year, or you will be removedfrom the waitlist.