Grace-Bankview Application for Accommodation Online version

Welcome to the

Grace-Bankview House Seniors Citizens Residence Society Application for Accommodation

Part A

By completing and submitting this application, you understand and agree with the following items checked:*

I understand that this is an application ONLY and that it is not an agreement on the part of Grace Bankview House Senior Citizens Residence Society or its agents, to provide me with rental accommodation.I further acknowledge the right of Grace Bankview House Senior Citizens Residence Society, or its agents, at any time prior to the execution and delivery to me a lease, to withdraw, or cancel, without penalty or liability for damages or otherwise, any prior approval of this application.I authorize Grace Bankview House Senior Citizens Residence Society, or its agents to investigate any or all of the statements made by me in this application, 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 Grace Bankview House Senior Citizens Residence Society, or its agents, in writing, of any changes in family composition, gross family income, assets, employment or changes of address, should they occur.I agree that I will be the sole tenant in the apartment being applied for. If I will be co- habitating with another person, I understand that they must meet all requirements for accommodation and complete a separate application.

Note: The personal information on this form is being collected for apartment leasing, under the authority of the Alberta Housing Act, Social Housing Accommodation Regulations and will be used to determine eligibility of Social Housing. It is protected by the Privacy Provisions of the Freedom of Information and Protection of Privacy Act (FOIP), If you have any questions about the collection, contact Grace-Bankview House Senior Citizens Residence Society, 3600 Sarcee Road S.W. Phone (403) 272-3055.

Instructions for use: All items with an asterisk * must be filled in before you can proceed to the next item.

Applications For Housing at (select one):*

Grace Lutheran ManorBankview House

1. Applicant Name*

First NameLast Name

2. Applicant Date of Birth*

Date

3. Co-Applicant Name

First NameLast Name

4. Alternate Contact Name*

First NameLast Name

Primary Number*

Alternate Number

5. I am a: ( Check One)*

Canadian CitizenLanded ImmigrantConvention RefugeeOther - Specify

6. Applicant Current Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

7. Applicant Telephone Number:

Primary Number*

Alternate Number

8. Do you rent or own your current accommodation?*

RentOwn

If you rent, please provide the following

Landlord's Name

First NameLast Name

Telephone Number

Landlord's Address

9. Which of the following describes your current accommodation:*

10. Number of people sharing your current accommodation:

Number of adults

Number of children

11. Do you require accommodation adapted for special needs? Example: wheelchair accessibility)*

YesNo

If Yes please describe

12. Do you have a certified service animal?*

YesNo

If Yes please describe

13. Please provide your current monthly accommodation expenses:

Rent or Mortgage payment*

Utilities (electricity, water, gas, sewer)*

TOTAL Monthly Accommodations Expenses*

14. Are you receiving Social Assistance/Alberta Works income?*

YesNo

If Yes, please provide the following:

Social Workers Name

First NameLast Name

Telephone Number

Social Workers Agency Name or Address

15. Are you currently employed?*

YesNo

If Yes, please provide the following:

Employer Name

First NameLast Name

Telephone Number

Employer Address

16. Assets: Please provide your current monthly income (Note: All income must be verified)

Old Age Security & Guaranteed Income Supplement*

Alberta Senior's Benefit Canada Pension Plan, Other Pensions*

Canada Pension Plan, Other Pensions*

Other Pensions*

War Veterans Allowance*

War Disability Pension*

Social Assistance/Alberta Works*

Employment Income*

Other Income Amount*

Other Income - Specify

Total Income*

17. Other Assets: Please list all (example: investments such as stocks, bonds, term deposits, bank accounts, real estate, etc.) Please provide your Total Asset Income:

Type of Asset

Monthly income from asset

Type of Asset

Monthly income from asset

Type of Asset

Monthly income from asset

Type of Asset

Monthly income from asset

Total Income*

18. What is your reason for moving?*

19. Have you applied for Senior Subsidized Accommodation with any other provincial housing?*

YesNo

20. Have you been given a "Notice to Vacate" at your current accommodation?*

YesNo

If Yes, please provide the reason for eviction:

Note: You may be required to submit a copy of the "Notice to Vacate" during the application review process.

21. Please provide two references who can be contacted in addition to your current landlord:

Friend Name*

First NameLast Name

Telephone Number*

Friend Address*

Family Member Name*

First NameLast Name

Telephone Number*

Family Member Address*

22. Other related information you wish to provide:

About The Application Process:

1. Once your application has been received and reviewed by Management, you will be called with an interview date and time.

2. All income must be verified prior to lease signing. Your Notice of Assessment from Revenue Canada for the past year is required to calculate the rental rate. This must be provided at the time of the interview. If your Notice of Assessment is not available, you must provide the last 3 months' bank statements from all bank accounts.

3. If you are a successful applicant:

i. Applicants should have a personal will and must provide the name and contact inforamtion for the will's Executor.

ii. Renter's insurance which includes liability is recommended.

iii. Appointment for lease signing by successful applicants will be coordinated by the Admin Assistant to occur during office hours.

iv. The applicant must be readily available to sign the lease and move in on the agreed upon date.

v. Keys are not issued until the lease is signed.

vi. Move ins can be scheduled through the office for weekdays between 8:00 am and 3:00 pm.

For questions contact the office at (403)242-3055 OR

by email grace-bankviewhouse@shaw.ca OR

by mail to: Grace Lutheran Manor Lutheran Manor

3600 Sarcee Road SW

Calgary, Alberta., T3E 6X5

The following information is required for safety reasons as per the Calgary Fire Department and the National Fire Code.

Date*

Date

Name*

First Name Last Name

1. Which of the following do you require to assist with your mobility?:*

*Wheelchair

Temporary usePermanent use

2. Which of the following visual aids do you require?:*

EyeglassesContact LensesNoneBlind person accessories - Specify

3. Do you require hearing aids*

YesNo

4. Is there anything else you may need assistance with should you be required to evacuate the building in the event of an emergency?*

NoYes

If Yes please specify

Note: This information is required at the time of application for accommodation and will be updated at the time of lease renewals. If any of the above information changes prior to the lease renewal period, it is the tenant's responsibility to notify management.

Welcome to the

Grace-Bankview House Seniors Citizens Residence Society Application for Accommodation

PLEASE READ CAREFULLY

PART B