WINNIPEG HOUSING 104-60 Frances Street, Winnipeg, Manitoba R3A 1B5 Ph. 949-2880 APPLICATION FOR HOUSING Please read carefully: Your eligibility for housing is primarily determined by income, assets, household composition, national occupancy standards, and reference checks. Date of Application (Please Print) (Last Name) (First Name) (Initial) Copy of photo identification must be provided with the application. Other names (Maiden Name, also known as) Social Insurance # Health Insurance # Phone Res. Cell Phone Work Phone Current Address City/Town Province Postal Code Are you a Canadian citizen? Yes No If "No", please provide Immigration Status Records. Marital Status Married Separated Divorced Widow(er) Common Law Single (If you are the co-applicant please complete the following) Co-Applicant (Last Name) (First Name) (Initial) Copy of photo identification must be provided with the application. Other names (Maiden Name, also known as) Social Insurance # Health Insurance # Phone Res. Cell Phone Work Phone Current Address City/Town Province Postal Code Are you a Canadian citizen? Yes No. If "No", please provide Immigration Status Records. Marital Status Married Separated Divorced Widow(er) Common Law Single Page 1 of 6
Has anyone on this application previously lived in WHRC Housing? If "yes", please show where and when: FAMILY INFORMATION For applicants on Social Assistance: Worker's Name Worker s Phone Number Worker s e-mail For co-applicants on Social Assistance: Worker's Name Worker s Phone Number Worker s e-mail Information about yourself and your family: Please read carefully. Write below your own name, etc. and also the name(s) etc. of all persons who will be living with you. OCCUPANT INFORMATION (Please list all household members that will be living in your household) Name Birthdate Gender M/F Relationship Next of Kin: (to be contacted in case of emergency) Name Address Name Address Relationship Phone Relationship Phone Is a member of your family disabled? Yes No If you answered "Yes",please describe the disability : Page 2 of 6
EMPLOYMENT INFORMATION PLEASE ATTACH PAY STUBS OR E.I. STUBS Employment Status: Employed E.I. Social Assistance Other, describe Present employer (if applicable) Name How long? Address CO- Employment Status: Employed E.I. Social Assistance Other, describe Present employer (if applicable) Name How long? Address PARKING How many parking spaces do you require: None 1 2 License plate number(s) FINANCIAL INFORMATION Do you own or share ownership in your present residence: Yes No If "No", how much monthly rent do you pay? $ Indicate by "Yes" or "No". Which of the following are included in your rent or show cost paid separately from rent: Heat Hydro Water Fridge Stove Parking Furniture Other ALLOWANCES Do you receive either of these allowances? Manitoba Child Tax Yes No If "Yes", show amount: $ Manitoba Child Benefit Yes No If "Yes", show amount: $ Page 3 of 6
DECLARATION OF GROSS MONTHLY INCOME INCOME SOURCE CO- CHILDREN OVER 18 OTHER OFFICE USE TOTAL Employment Income Tips/Overtime/Bonus/Commissions Maintenance & Child Support Self-Employed Earnings Babysitting or Fostering Rental Income Investment Income Student Support Employment Insurance Employment & Income Assitance Workers Compensation Canada Pension Old Age Security/GIS 55 Plus Company Pension Veteran Allow ance (Canadian & Foreign) Disability DVA Disability from all sources Widow s Pension Survivors Pension Orphans Pension Annuities Trust Funds Gifts (of any kind) Other Total Monthly Income x12 Mths Instructions: PLEASE FILL IN THE AMOUNTS FOR INCOME SOURCES THAT APPLY TO YOU AND YOUR FAMILY, THEN SIGN THE DECLARATION BELOW. PLEASE BE AS ACCURATE AS POSSIBLE AND REMEMBER THE INCOME AMOUNTS REQUIRED ARE GROSS AVERAGE MONTHLY. REMEMBER TO ATTACH ALL SUPPORTING DOCUMENTS FOR EACH SOURCE OF INCOME WHERE APPLICABLE. I HEARBY CERTIFY THAT THE INFORMATION GIVEN IN THIS STATEMENT IS TRUE, CORRECT, AND COMPLETE IN EVERY ASPECT, AND FULLY DISCLOSES MY INCOME FROM ALL SOURCES. Date Applicant Co - Applicant Page 4 of 6
LANDLORD INFORMATION Please provide your rental history starting with your current landlord information 1. Current Address Name of Landlord Phone Number e-mail 2. Past Address 3. Past Address CO 1. Current Address 2. Past Address 3. Past Address Page 5 of 6
WHY ARE YOU APPLYING FOR HOUSING? (if more than one reason, please number by importance) Unable to afford present rent Unable to afford increased mortgage, utilities, taxes Building being demolished Leaving at landlord's request Can no longer stay with family/relations/friends Family separation Present place too small Other (explain) Listed below are the areas in which we currently have housing. Please indicate which locations may be of interest to you and your family at this time. Yes No A. Central Park Area (Sargent Ave/Cumberland Ave/ Frances St) B. Health Sciences Centre Area (Alexander Ave/ McDermot Ave/ Pacific Ave/ Sherbrook St/William Ave) C. Misericordia Hospital Area (Sara Ave/ Young St.) D. North End Area (Burrows Ave/Charles St/McKenzie St/Manitoba Ave/Selkirk Ave Flora Place) E. Slaw Rebchuk/Salter Bridge (Henry Ave/Laura St/Sherbrook St/Logan Ave Salter St) F. U of W/Hudson Bay Area (Colony St/Young St.) G. West End Area (Furby St/ Toronto St./Victor St./Langside) H. Osborne Village Area (Roslyn Rd.) I. Seniors Building (Stradbrook Ave/Mountain Ave/Selkirk Ave/ Keewatin Ave) AUTHORIZATION AND DECLARATION I/we understand that this application does not constitute an agreement on the part of Winnipeg Housing Rehabilitation Corporation or its agent to provide me/us with rental accommodation. I/we acknowledge that this application becomes the property of Winnipeg Housing Rehabilitation Corporation upon delivery by me/us to it or its agent. I/we further acknowledge the right of Winnipeg Housing Rehabilitation Corporation or its agent 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/we certify that the information given in this application is true and correct and complete in every respect and fully discloses my/our income from all sources. False information will result in this application being declined or will terminate your tenancy once you move in based on false information. Personal information is collected by Winnipeg Housing Rehabilitation Corporation and will be used to establish eligibility for rental housing. It is protected under The Personal Information Protection and Electronic Documents Act (PIPEDA). I/we hereby authorize Winnipeg Housing Rehabilitation Corporation to conduct a personal investigation including past and present landlord reference checks. Applicant name Applicant signature Date Co-Applicant name Co-Applicant signature PLEASE RETURN TO: Date WINNIPEG HOUSING REHABILITATION CORPORATION 104-60 FRANCES STREET, WINNIPEG, MANITOBA R3A 1B5 Page 6 of 6