VC Application for Accommodation

(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)

Last name	First name	Relationship to Applicant	Date of Birth (dd/mm/yyyy)	Gender Identity	Born in Canada? (Y or N)	Status in Canada

2.Residential Address

Apt #	Street #	Street Name	City	Postal Code

Mailing Address If different from home address

Apt #	Street #	Street Name	City	Postal Code

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.

RENT CALCULATION

Residents pay 30% of their monthly income.
Rent is recalculated once a year.
Add to this a meal, once per day at noon
2 meal options to choose from per day, billed separately,
As a hospitality charge of $235.00 per month. This is mandatory.

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.

Name	Relationship	Phone Number

6. Asset Information
What is the total value of assets for adults in the household?

Counted	Not Counted
• 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
• TFSA

* 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.

Name	Income Source (employment, EI, pensions, Income Assistance, etc.)	Gross Monthly Income ($)	Disability Income? Y or N

8. Current Accommodations
8a. Are you renting? YesNo
If you are renting, how much is your monthly rent payment?

8b. Please describe your current living arrangements.
House/TownhouseApartment/BasementManufactured Home/TrailerSleep OutsideStaying with FamilyStaying with FriendsMotel/HotelTransition HomeSecond Stage HousingCare Facility or Treatment CentreEmergency ShelterOther:

8c. Have you received a legal Notice to End Tenancy? YesNo

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?
I/We can do stairsI/We cannot do stairsI/We can only do a few stairs. How many? steps

9b. Do you, or any member of your household, use a:
Wheelchair? YesNo Scooter? YesNo

If yes, who? Used inside the home? YesNo

9c. Please only list health conditions that would affect your housing needs.

Name of Household Member	Health Condition or Disability

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?
YesNo

10b. Are you willing to live in a pet free building and sign a no pet agreement?
YesNo

10c. Do you have a dog that is accredited under the “Guide Dog and Service Dog Act”?
YesNo 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
__________________________________________________________________________________________
I/We declare:
• This is my/our application; and
• All the information in it is correct and complete to the best of my/our knowledge.
_________________________________________________________________________________________
I/We permit:
• 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.
_________________________________________________________________________________________
I/We understand:
• 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.