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LU’MA NATIVE HOUSING SOCIETY
132 328 Wale Rd, Colwood, BC V9B 0J8
Website: www.lnhs.ca Email: colwood@lnhs.ca
| F: (604) 876-0999
APPLICATION FOR HOUSING
PLEASE PRINT DATE: _______________
Full Name:
Cell:
Address:
Suite:
Home:
City:
Prov:
Postal:
Work:
Email:
Message:
TYPE OF HOUSING
I am in need of Subsidized Rent Market Rent
HOUSEHOLD COMPOSITION
Full Name:
Birthdate
(DD/MM/YY)
Relationship to Applicant
APPLICANT
APPLICANT
Do you expect your family size to change within the next 12 months? Yes No
Reason: ___________________________________________________________________________________________
First Nations, Metis, and Inuit
Nation/Community
INCOME INFORMATION
List GROSS (before taxes) monthly income for members over 19 from all income sources.
Name
Source
(School funding, Employment, EI, Social Assistance, etc.)
Amount
Total Monthly Gross Income
HOUSING INFORMATION
Do you or a member of your household require accessible or supportive housing? Yes No
Name
Accessible
Provide Details:
(e.g. wheelchair accommodation, home support services, limitations
doing stairs)
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RENTAL HISTORY
Please list your address(es) for the past 3 (three) years. Must be completed.
Address:
Date: From To
Name of Landlord
Number
Have you at any time lived in Social Housing? Yes No
If yes, what was the organization? _____________________________________________________________________
What were the dates of residency? From ________________ To ________________
CURRENT ACCOMMODATION
Please describe your current accommodation as completely as possible by completing the information below.
Please check one:
Apartment
Basement Suite
Couch Surfing
Emergency Shelter
Homeless
Hotel/Motel
House/Duplex/Townhouse
Housekeeping Room
Living with family members
Room & Board
Single family dwelling
SRO
State the following
Number of Bedrooms:
Monthly Rent:
Monthly Utilities:
Check one:
Rent
Own
Do you currently:
Share Expenses
Have Free Accommodations
Other: ______________________________________
Does your current accommodation have:
Bathroom:
Kitchen:
Laundry:
Shared
Shared
Shared
Private
Private
Private
N/A
N/A
Do you have any household pets?
Yes
No
Specify: ______________________________
Have you been given a “Notice to End Tenancy”? Yes No
If yes, please attach a copy of the “Notice to End Tenancy” from your landlord.
If you are not under Notice to End Tenancy, why do you wish to move? (Please be specific)
APPLICANT SIGNATURE: (Please read and sign this statement)
I understand that this application does not constitute any agreement on the part of Lu'ma Native Housing Society to
provide me with rental accommodation. I hereby certify that the information given in this application is true, correct,
and complete in every respect to the best of my knowledge and will be verified, if so required by Lu'ma Native Housing
Society. I understand that it is my responsibility to advise Lu'ma Native Housing Society of any changes to the
information given above.
SIGNATURE:
DATE:
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