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LUMA NATIVE HOUSING SOCIETY 2960 NANAIMO STREET VANCOUVER,

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  • 31 check-boxes
  • 74 other fields

Country of origin: CANADA
File type: PDF

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1 | P a g e
LU’MA NATIVE HOUSING SOCIETY
2960 NANAIMO STREET VANCOUVER, BC V5N 5G3
Website: www.lnhs.ca Email: info@lnhs.ca
Phone: (604) 876-0811 | 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:
SEX
(M/F)
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 an accessible unit or have restrictive mobility? ☐ Yes ☐ No
Name
Accessible
Provide Details:
(e.g. wheelchair accommodation, home support services, limitations doing
stairs)
☐
☐
2 | P a g e
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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Completed 9 March 2021

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