Community Housing Application
Please read the following information carefully before completing the application. If you have any questions,
please contact Capital Region Housing (CRH) as listed above.
1. Please complete and sign the application in ink.
2. Return your application to Capital Region Housing by mail, fax or in person.
3. Answer all the questions in the application, if a question does not apply to you print NA (not
applicable). Please do not leave any blanks.
4. All income reported must be supported by documentation.
5. All co-applicants must sign the completed form.
6. Please ensure that all information and documents submitted in and with the application are true to the
best of your knowledge.
Your application must include:
Proof (documentation) of all income and money listed in this application for all applicants from any
sourcefor example, pay stubs, benefits summary, bank statements.
Bedroom listing based on
your household size.
Depending on your situation, you may need to include:
Notice to Vacate or Foreclosure Papers
Pet Application
Live in Aide Form
Consent to Release Form
Proof of assets (including property, car ownership, shares and rental revenue)
Proof of student status for all family members 15 years and older who have income from any source
and go to school full time.
If you visit the office or speak with a CRH representative about your file over the phone, please be ready to
verify your identity. If you would like someone who is not listed on the application to be able to speak with CRH
on your behalf or about your application, please complete a Consent to Release form.
Submit Applications to:
Capital Region Housing
10232 112 Street NW
Edmonton, Alberta T5K 1M4
Phone: (780) 420-6161
Fax: (780) 426-6854
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APPLICATION FOR COMMUNITY HOUSING
Please complete the following information to the best of your ability.
I have filled out this form with accurate information to the best of my knowledge.
(Name)
Signature
Date (MM/DD/YYYY)
SECTION ONE- APPLICANT INFORMATION
To be completed by the primary applicant using names indicated on government issued identification. For example, Given Name must
be exactly as it is on government issued identification.
Family Name Given Name Middle Name(s)
Preferred Name (if applicable)
Home Telephone No. Work Telephone No. Cell No. Email
Current Address Postal Code Mailing Address (if different from Current Address)
Date of Birth
MM DD YYYY
Self-Identify
Canadian Citizen
Permanent Resident
Government Sponsored Refugee
Other If other, please explain:
Yes No
If yes, indicate status Full Time Part Time
Gender
M F
Status in Canada
Are you a student?
Do you have income?
Yes No
Have you ever received services from CRH?
Yes
No
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click to sign
signature
click to edit
SECTION TWO- HOUSEHOLD INFORMATION
To be completed for ALL members of household (other than the main applicant) who will be living with you, regardless of age, r
elationship or
status in Canada. Provide information as it appears on government issued identification. Capital Region Housing can speak with
anyone listed as a part of the household about the contents and status of the application and file.
Full Legal Name
Relationship
to
Applicant
Gender
Date
of
Birth
(MM/
DD/
YYYY)
Status in Canada
Is this
person a
full-time
student?
Canadian
Citizen
Permanent
Resident
Government
Sponsored
Other
(specify)
Family Name
Given Name(s)
including middle nam
es if
applicable
Are you expecting any changes to the total number of household members within the next three months? (For example, someone moving
in or out, birth of a baby, etc.)
If yes, please explain
SECTION THREE- RENTAL INFORMATION List all the details of your housing history, starting with where you live now.
Current Housing Information
Start of occupancy
Do you pay room and board?
Y
es No
How many bedrooms do the people on the application currently occupy?
1
2
3
4
5
Over 5
How many bedrooms are in the unit you rent? ________
Which utilities do you pay? (Check all that apply)
Power
Heat
Water and Septic
Cost of rent $
Do you have a written tenancy agreement? Yes No
Does your rent include parking? Yes No
Current Landlord Information
Name
Address
Email
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Telephone
--
--
--
--
--
Previous Information Complete the following with details about your housing history for the past 2 years
Previous Address
Date of occupancy
from
MM DD YYYY
to
MM DD YYYY
Previous Landlord Information
Name
Address
Telephone
Would this landlord provide a good reference? Yes No If no, why?
Reason for move:
Previous Address
Date of occupancy
from MM DD YYYY to MM DD YYYY
Previous Landlord Information
Name
Address
Telephone
Would this landlord provide a good reference? Yes No If no, why?
Reason for move:
If you need more space, please use the back of this page if blank or add another page.
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Email
Email
SECTION FOUR- CURRENT INCOME AND ASSETS
EMPLOYMENT
Complete the following for all members of your household, including dependents over the age of
15 who are currently employed. If you
are self-employed listself” in the employer box.
Full Name
Employer
Dates of Employment
MM/YYYY to MM/YYYY
Payment Information
Hourly Pay
Salary
Pay/Hour
Hours/Week
/ to /
/ to /
/ to /
/ to /
/ to /
OTHER INCOME
Please list all income you or a household member 15 years or older gets on a regular basis and include documentation.
Source of Income
Name(s) of Recipient(s)
(list all members who get this source of income)
Alberta Seniors Benefit (ASB)
Assured Income for the Severely Handicapped (AISH)
Alberta Child Benefit
Band and/or Treaty Funding
Canada Pension Plan (CPP)
Child Support (including section 7 expenses)
Child Tax Benefit
Company/Group Pensions
Disability Benefit
Employment Insurance
Family Tax Benefits
Foreign Country Income
Government Family Support (i.e. kinship, foster)
Home Based Business
Income Support/Social Assistance
Old Age Security (OAS)/ Guaranteed Income Supplement (GIS)
Partner/Spousal Support
Resettlement Assistance
Self Employed
Student Funding
Student Loans/Grants
Support from family
Tips
Workers' Compensation Board (WCB)
Rental Income
GST
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What is your total gross household per month from all sources? ________________________________________________________
ASSETS
Complete for all members of the household listed on the application.
Note: RRSPs, RESPs, RDSPs and TFSAs are exempt assets and do not need to be disclosed.
VEHICLE(S)
Do you have a vehicle? Yes
No
No
Do you have more than one vehicle?
Yes
If so, how many vehicles do you have?
Make
Model
Year
Kilometers/Mileage
Payment Each Month
Vehicle One
$
Vehicle Two
$
Vehicle Three
$
Are any of your vehicles financed?
Yes No
If yes, please provide documentation.
SECTION FIVE SPECIAL CIRCUMSTANCES
Check all that apply for you and your
household. Explain in the space provided below and provide documentation where appropriate.
Have been served a notice to vacate or have been evicted
Accommodation is not accessible or adaptable for the physical circumstances
Home is in the process of foreclosure
Selling a home that I/we own
About to be released from a program or facility and have nowhere to live
Fleeing family or other violence/abuse
Homeless or at risk of homelessness
Living in dangerous housing conditions (eg. broken doors, lights don’t work, Alberta Health Services has been to your home)
Living in a hotel/motel
Living in a group home
Living in a shelter
Living with family or friends
In bankruptcy or have filed a consumer proposal
Graduating from Housing First
Assets
Total Value/Amount
Property
$
Cash/Money in Bank
$
Stocks, Bonds, GICs
$
Other Investments or Income
(Including foreign sources)
$
$
Other
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Other:
Do you have a pet that will be living in your household?
Yes
No
If yes, complete a Pet Application for permission. Approval is subject to the landlord; some rental
properties do not allow pets.
Do you have a service dog?
Yes
No
Service dogs must be qualified under the Service Dogs Act (Alberta). Please include a copy of
the
qualifications documents
Do you have a live-in aide (someone who lives with you, takes care of you, and is paid?
Yes
No
If yes, complete the Live In Aide
Application
This personal information is being collected under the authority of section 33(c) of the Freedom of Information
and Protection of Privacy Act (FOIP) and/or in accordance with any applicable agreements in place. All personal
information collected during the application process, during the course of the customer(s)’s stay, and for
participation in any programs will be used to provide services and ensure a safe and secure environment of all
our customers. Your information will be treated in accordance with the privacy provisions of Part 2 of the
FOIP Act. Limited information may also be used by Capital Region Housing and/or provided to the
Minister of Seniors and Housing for the purpose of developing programs, activities or policies (e.g.
research, statistical analysis) or for receiving provincial and/or federal funding. If you have any questions,
please contact our FOIP Coordinator at 780-420-6161 or at FOIPCoordinator@crhc.ca.
Send applications to:
Capital Region Housing
10232 112 Street NW
Edmonton, Alberta T5K 1M4
Phone: (780) 420-6161
Fax: (780) 426-6854
Use this space to explain special circumstances
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AUTHORIZATION
All applicants over the age of 18 years must complete the sections below, as applicable.
To apply for community housing, you MUST agree to the two points below. I/We authorize
Capital Region Housing to make any
inquiries necessary to any government office, organization,
agency or individual for the purposes of verifying information provided in this application.
Initial Initial Initial Initial Initial Initial
Capital Region Housing to contact and receive information from current and/or previous
landlords to complete reference checks for the purposes of assessing suitability as a
prospective tenant.
Initial Initial Initial Initial Initial Initial
The following two are OPTIONAL. You do not need to agree to these in order to apply for
community housing. I/We authorize:
Capital Region H
ousing to contact me for research purposes all information will remain
anonymous, and I/we can decline participation at any time.
Initial Initial Initial Initial Initial Initial
Capital Region Housing to use my email address for the purposes of communication including, but
not limited to, newsletters, surveys and information.
Initial Initial Initial Initial Initial Initial
I/We understand:
This application is not an agreement on the part of Capital Region Housing to provide me/us with
housing.
A failure to respond to requests for additional information or documentation by Capital Region Housing
may result in the application being put on hold or cancelled.
Providing false information to Capital Region Housing may result in the application being cancelled or
no longer being eligible for services.
If I/we are being considered for an available unit, Capital Region Housing may need additional
information to make sure all my/our information is up to date and that my/our household still qualifies.
It is my/our responsibility to keep Capital Region Housing updated on any changes to my/our
circumstances or the information provided in this application.
Application must be signed by the Applicant and members of the household over 18 years of age.
Print Name Signature
Date
(MM/DD/YYYY)
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