APPLICATION INFORMATION PAGE - PLEASE READ
Have you reviewed the Application Information Page in full?
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Please Select
Yes
No
Selecting yes is a confirmation that you have read and understood the information presented in the preceding document.
Have you ever received funding from the Good Neighbour Fund?
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Please Select
Yes
No
The Good Neighbour Fund provides one-time support to successful applicants. If you have received funding from our organization in the past, you are ineligible to apply.
Eligible to Apply
You are eligible to apply for one-time funding from the Good Neighbour Fund. Please review the Application Information Page above and answer all questions below.
Ineligible to Apply
The Good Neighbour Fund provides ONE-TIME support to successful applicants. You have indicated that you have received funding from our organization in the past. If that is the case, you are ineligible to apply.
Applicant's Information
Please answer ALL questions in the order they are presented
Date of Application
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Month
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Day
Year
Date
Name
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First Name
Last Name
Date of Birth
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Day
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Month
Year
Days
Age
Phone Number
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Please enter a valid phone number.
Email Address
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Format: example@example.com
Current Address (Applicants must reside within 100km of Edmonton, AB)
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Unit Number
Street Address incl. Unit Number (if applicable)
City
Province
Postal Code
Please upload a picture or scan of your current GOVERNMENT ISSUED PHOTO IDENTIFICATION (eg. driver's license, passport).
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APPLICANTS MUST INCLUDE PHOTO IDENTIFICATION.
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How long have you lived at your current address?
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Please Select
Less than two years
More than two years
Previous Address (Please list ALL addresses at which you have resided within the past two years)
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What is your current living situation? Please check ALL that apply.
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Live alone
Live with spouse or partner
Live with children or dependants
Live with parent or guardian
Live in shared accommodation with another adult
Other (please explain below)
Children or dependants under your direct care
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Spouse, partner, parent, or adult you reside with (Please list ALL that apply)
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Are you currently employed?
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Yes
No
Are you employed full-time or part-time?
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Full-Time
Part-Time
Who is your employer?
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How long have you been employed with your current employer?
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PLEASE USE MONTHS AND/OR YEARS
Please provide a contact name for your employer (eg. supervisor, manager, owner)
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First Name
Last Name
Please provide the phone number for the individual listed above
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Please enter a valid phone number.
Please upload a copy or clear photo of your most recent paystub.
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For how long have you been without employment?
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PLEASE USE MONTHS AND/OR YEARS
Are you currently seeking employment?
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Please Select
YES
No
Why are you not currently seeking employment?
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0/250
What are your current job prospects? With what companies have you applied for work? Have you had any job interviews via phone or in-person?
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0/250
APPLICANT'S MONTHLY INCOME: Please complete the table in full for ALL sources of income that apply. Enter 0 in the field if it does not apply.
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Monthly Income ($)
Net Employment Income (after taxes)
Income Support
AISH
Employment Insurance
Workers Compensation
Disability Support
Pension
CPP
Old Age Security
Student Loan
Canada Child Benefit
Child Support
Spousal Support
Other (please include ALL other sources here)
Employment Income
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Child Support
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Student Loan
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Employment Insurance
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Proof of Income Trigger
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Applicants Total Monthly Income from ALL Sources
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You have indicated an amount of employment income while also indicating you do not have employment in a previous question. Please correct this above or explain below.
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You have indicated that you live with children or dependants and not with a spouse or partner. Do you receive monetary support from the child or children's other parent? If so, please include that amount in the monthly income table above.
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Please provide PROOF OF INCOME for the applicant if applicable (eg. government deposit confirmation, government funding statement, and/or bank statement)
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If you receive funding from any source not indicated on your pay stub, it MUST be included here.
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You have indicated that you received a provincial or federal student loan, please upload your most recent Notice of Assessment or loan funding statement.
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You have indicated that you are receiving employment insurance benefits, what is the expiry date?
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Day
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Month
Year
Is your spouse/partner currently employed?
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Yes
No
Is your spouse/partner employed full-time or part-time?
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Full-Time
Part-Time
Who is your spouse's/partner's employer?
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How long has your spouse/partner been employed with their current employer?
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For how long has your spouse/partner been without employment?
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PLEASE USE MONTHS AND/OR YEARS
Is your spouse/partner currently seeking employment?
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Please Select
YES
NO
Why is your spouse/partner not currently seeking employment?
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0/250
What are your spouse/partner's current job prospects? With what companies have they applied for work? Have they had any job interviews via phone or in-person?
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0/250
SPOUSE/PARTNER MONTHLY INCOME: Please complete the table in full for ALL sources of income that apply. Enter 0 in the field if it does not apply.
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Monthly Income ($)
Net Employment Income (after taxes)
Income Support
AISH
Employment Insurance
Workers Compensation
Disability Support
Pension
CPP
Old Age Security
Student Loan
Canada Child Benefit
Child Support
Spousal Support
Other (Please include ALL other sources here)
Spouse or Partner's Total Monthly Income from ALL Sources
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Do the other adults with which you reside contribute toward monthly household expenses? If not, explain why they do not contribute.
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If so, how much do they contribute to the monthly household expenses?
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Calculated Monthly Income
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Monthly Income
Applicant's Income
Spouse's Income (if applicable)
Additional Adult Contributions (if applicable)
Total Monthly Household Income
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Do you own your home?
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Yes
No
What is the approximate value of your home?
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What is the amount remaining on your mortgage?
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Do you (or your spouse/partner) own or lease a vehicle?
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Yes
No
Please list ALL vehicles
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Do you (or your spouse/partner) have any investments including RRSP, GIC, or Savings?
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Yes
No
What is the total value of these investments?
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Have you (or your spouse/partner) received, or will be receiving, money from insurance or an insurance settlement?
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Yes
No
What is the total value of the insurance settlement?
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MONTHLY EXPENSES - if you are living in shared accommodation please indicate YOUR monthly portion only.
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Monthly Expenses
Rent/Mortgage
Gas/Heat
Electricity/Power
Water
Phone (Mobile or Home)
Internet
Cable TV
Entertainment Subscriptions (eg. Netflix, Apple)
Groceries, Food, & Personal Hygiene
Clothing
Medical Needs
Child Care
Vehicle Payments
Vehicle Insurance
Vehicle Fuel
Vehicle Maintenance
Transportation (eg. bus pass, Uber, taxi)
Other (Please explain below)
Other
Vehicle Expenses
You have indicated a response of Other related to monthly expenses, please explain.
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You have indicated that you have vehicle expenses, but have not indicated owning a vehicle when asked previously in the application. Please correct this above or explain this in the space below.
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Total Monthly Expenses
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Financial Sustainability Measure - Internal Use Only
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REQUEST FOR FUNDING
What do you require funding assistance for? In order to apply for housing support, you MUST include a copy of your LEASE AGREEMENT, STATEMENT OF ARREARS, AND/OR EVICTION NOTICE, if one has been issued. To apply for utility support, you MUST include the FULL UTILITY BILL.
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Amount Requested
Rental Arrears
Damage Deposit
First Month's Rent
Utility Arrears
Groceries, Food, & Personal Hygiene
Household Items or Furniture
Clothing
Medical Equipment or Supplies
Other
Rental Arrears
Damage Deposit and/or First Month's Rent
Utility Arrears
Groceries, Food, Clothing, Personal Hygiene, Household Items, Furniture, Other
Medical Equipment & Supplies
Total Amount Requested
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Please explain your request in as much detail as possible.
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0/250
You have indicated a request for support with RENTAL ARREARS. Please upload your entire LEASE AGREEMENT and STATEMENT OF ARREARS. If you have an EVICTION NOTICE, please upload that here as well.
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If you do not include proper documentation to support your request for funding your application will not be considered by our Board of Directors.
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You have indicated a request for support with a DAMAGE DEPOSIT and/or FIRST MONTH'S RENT. Please upload your entire LEASE AGREEMENT.
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If you do not include proper documentation to support your request for funding your application will not be considered by our Board of Directors.
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You have indicated a request for support with UTILITY ARREARS. Please upload ALL PAGES your most recent UTILITY BILL or BILLS.
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If you do not include proper documentation to support your request for funding your application will not be considered by our Board of Directors.
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You have indicated a request for support with MEDICAL EQUIPMENT OR SUPPLIES. Please upload TWO QUOTES for the requested items.
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If you do not include proper documentation to support your request for funding your application will not be considered by our Board of Directors.
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APPLICATION QUESTIONNAIRE
Please provide sufficient detail to ensure the Board of Directors understand your request.
Please explain the circumstances that led to your current situation and resulted in this request for funding from our organization?
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0/250
Our Board of Directors looks closely at financial sustainability when making their decisions. Considering the income and budgeted expenses within the application, finances will be highly restrictive. Is there a plan in place to compensate for this on an immediate and ongoing monthly basis?
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0/250
Our Board of Directors looks closely at financial sustainability when making their decisions. Considering the income and budgeted expenses within the application, finances do not appear to be particularly restrictive. Please provide details to justify your application for funding from our organization.
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0/250
Our organization is unlikely to have the capacity to support the entirety of your request. Our successful applicants commonly receive between $250.00 and $2,000.00 in one-time funding. Would you like to adjust your request to fit within these parameters?
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0/250
Based on this adjustment, please provide a detailed outline of how you plan to handle the remainder of your request. How will you pay the outstanding amount?
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0/250
Do you have any family or friends who will be willing or able to provide financial assistance at this time to support with this specific request?
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0/250
What changes will you be making to ensure this type of expense will not be an issue in the future?
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0/250
What is your alternate plan should you not receive funding from our organization?
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0/250
The Good Neighbour Fund is a charity of LAST RESORT, it is expected that you have exhausted ALL other funding options prior to submitting your application to our organization.
Please list all other agencies or organizations that you have contacted for assistance with this request?
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If you have NOT exhausted ALL other funding options for this request, please explain why.
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0/250
Have you received financial assistance or support in the past five (5) years from any public or private organization?
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Yes
No
Please list all other agencies or organizations from which you have received funding in the past five (5) years.
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LETTER OF SUPPORT
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THE APPLICANT IS STRONGLY ENCOURAGED TO INCLUDE AN OFFICIAL LETTER OF SUPPORT FROM A SOCIAL WORKER, SUPPORT WORKER, OCCUPATIONAL THERAPIST, OR HEALTHCARE PROFESSIONAL. THE LETTER MUST BE ON OFFICIAL LETTERHEAD AND INCLUDE THE CONTACT INFORMATION OF THE WRITER.
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Additional Information
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IF THERE IS ANYTHING ELSE YOU WOULD LIKE TO SHARE THAT WOULD SUPPORT YOUR APPLICATION, PLEASE ATTACH IT HERE.
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Application Declaration
I have read and understand the above declaration.
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Yes
Please verify that you are human
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Signature of Applicant
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