(PLEASE PRINT OR TYPE CLEARLY)
For assistance in completing this form, please contact PDCSS at 250-295-6666
1. Applicant Information (Person(s) applying for accommodation)
Mailing Address If different from home address
3. Contact Information
Note: By providing an authorized contact, you are giving permission for PDCSS to exchange information with that authorized contact in order to maintain and update your file. To remove an authorized contact, please contact PDCSS.
4. Residence History
Please provide information on where you have lived for the last five years. At least one reference (landlord or character) is required. If space is needed, attach a separate sheet.
Have you previously lived in subsidized accommodation?
Check if yes.
If so, list the names on the tenancy:
Building name and address:
What were the dates of your residency? From To
5. References (Optional)
If you did not list a current or previous landlord in Question 5, please include a reference that has observed your character over a reasonable amount of time. Examples: employer, past employer, pastor, outreach worker or health worker.
6. Asset Information
What is the total value of assets for adults in the household?
• Stocks, bonds, term deposits, mutual funds, and cash
• Personal items such as vehicles, jewelry and furniture
• Real estate equity (net value after mortgage
• Bursaries or scholarships from educational institutes for
any household member who is currently a student
• Business equity in a private incorporated company
including cash, GIC’s, bonds, stocks or real estate
• RRSP, RESP, RDSP or RRIF
* Please provide the suggested proof of assets documents as stated in the checklist*
7. Income Information
List all gross (before deductions) monthly income for household members. If required, attach a separate sheet.
8. Current Accommodations
8a. Are you renting? Yes No
If you are renting, how much is your monthly rent payment?
8b. Please describe your current living arrangements.
House/Townhouse Apartment/Basement Manufactured Home/Trailer Sleep Outside Staying with Family Staying with Friends Motel/Hotel Transition Home Second Stage Housing Care Facility or Treatment Centre Emergency Shelter Other:
8c. Have you received a legal Notice to End Tenancy?
If yes, when do you have to move out by?
*Please provide a copy of the Notice to End Tenancy form (if applicable) as stated in the Additional Documents section*
8d. Is there anything else that you want to share with a potential landlord about your current living situation?
9. Health & Mobility Information
9a. Do you, or any members of your household, have challenges with stairs?
How many? I/We can do stairs I/We cannot do stairs I/We can only do a few stairs. steps
9b. Do you, or any member of your household, use a:
Wheelchair? Scooter? Yes No
If yes, who?
Used inside the home?
9c. Please only list health conditions that would affect your housing needs.
9d. Please describe any health concerns that are affected by your current housing.
9e. Please describe any special requirements or features that you may need in your housing (e.g., grab bars, near transit). Please note that special requirements or features may limit the number of units that you are eligible for.
10. Housing Options
10a. Are you willing to live in a non-smoking/vaping free building and sign a non-smoking agreement?
10b. Are you willing to live in a pet free building and sign a no pet agreement?
10c. Do you have a dog that is accredited under the “Guide Dog and Service Dog Act”?
Please submit proof of guide dog accreditation (if applicable)
11. Optional Supplemental Application (if applicable)
Additional consideration may be given to applicants who
• Are homeless;
• Are fleeing domestic violence or abuse; or
• Have a serious health condition that is affected by current housing.
Applicants who meet these criteria can have a Supplemental Application form completed by a third-party verifier familiar with their situation. Please find a list of appropriate potential verifiers within the supplemental form.
PLEASE READ AND SIGN
• This is my/our application; and
• All the information in it is correct and complete to the best of my/our knowledge.
• PDCSS to make any inquiries that are necessary to verify the information given in this application;
• Any person, corporation or social agency to release to PDCSS any information pertinent to the assessment of my/our application;
• Members of PDCSS to receive and exchange with credit bureaus and my/our previous landlords’ credit and other tenancy information about me/us, to be used in the decision-making process to provide me/us with housing;
• The Ministry of Social Development and Poverty Reduction to release information to PDCSS regarding my/our income.
• That, in accordance with section 33.2 (a) of the Freedom of Information and Protection of Privacy Act, the information on this application may be shared with other affordable Housing Providers in order to increase my/our opportunities for housing;
• That this application is not an agreement on the part of PDCSS or its staff to provide me/us with housing;
• That if I/we refuse two offers of housing, my/our application will be cancelled;
• That if I/we are being considered for an available unit, Housing Providers will gather additional information in order to assess my/our ability to uphold the obligations of a tenancy agreement and it is my/our responsibility to provide or cause to be provided information requested to assist with this assessment;
• That it is my/our responsibility to tell PDCSS of any changes to the information given in this application and to provide any supporting documents required;
• That false information given by me/us may result in my/our application being cancelled from consideration;
• That if I/we have deliberately worsened my/our current housing situation (e.g., terminated a tenancy for no reason) that my/our application may not be accepted or my/our current living situation may not be taken into consideration
This application must be signed by all household members aged 19 and older.
Purpose of this form: This form collects personal information for contact purposes and to determine eligibility for temporary housing.
Please do not submit original documents.
Proof of income or disability assistance
If receiving income assistance or disability assistance from the Ministry of Social Development and Poverty Reduction: copy of cheque stub or confirmation of monthly assistance.
If employed: proof of current gross monthly income (last three consecutive cheque stubs or a letter from your employer)
Copies of cheque stubs, bank statements showing direct deposits of pensions, or other confirmation of income for any other income source, for the last three months.
Proof of assets
Copies of bank statements or letter from financial institution stating total value of asset(s).
Property tax assessments for value of property owned and proof of outstanding mortgage(s) if you own property.
Additional Documents (if applicable)
The Supplemental Application Form is available at the PDCSS office.
IMPORTANT: PLEASE SEND ONLY THE DOCUMENTS REQUESTED.
Do not send original documents. Submitted documents will not be returned.
Please review this checklist and make sure that, when this application is sent in, all documents are included. Missing information will delay the processing of your application.
Submit your completed application with supporting documents:
120 Veteran’s Blvd.