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Rdha Application Fillable (Augustana University College)

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302, 4719 – 48 Avenue
Red Deer, Alberta T4N 3T1
Phone: (403) 343-2177
Fax: (403) 343-2176
Email: admin@rdha.ab.ca
Application for Community Housing and Rent Supplement Programs
Instructions
Please read the following information carefully before completing the application. 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. If you have
any questions, please contact Red Deer Housing Authority as listed above.
1. Please review information on Eligibility Requirements and Point Scoring for the purposes of determining need
for social housing. Priority is decided based on a points system according to the Social Housing Accommodation
Regulation. Households with the greatest number of points are considered in greatest need of housing
accommodation and must be allocated housing accommodation on that basis. If your information changes
at any time, please contact us and let us know – this may impact your point score.
2. You may print the application form and fill it in by hand, or complete it online using an electronic signature.
Once done, please save or scan your completed application form in PDF format and attach it along with
your documents as part of your application and email it to admin@rdha.ab.ca or drop/mail it to our Offices
at, 302, 4719 – 48 Avenue, Red Deer, Alberta T4N 3T1.
3. You will be required to provide the following:
• Documentation to verify all sources of household income. i.e.: pay cheque, benefit cheque, child support,
AISH, Social Assistance, Student Funding etc.
• Verification of your government issued picture ID.
• A Copy of most recent Notice of Assessment (Revenue Canada)
• Copy of Alberta Heath Care Card for each member of the household.
• For Rent Subsidy Applications we also need a copy of your lease (if applicable)
• If not a Canadian Citizen, proof of permanent residency/refugee status.
4. Please ensure that all information and documents submitted in and with the application are true to the best
of your knowledge.
5. If you visit the office or speak with a RDHA 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 RDHA on your behalf or about your application, please complete a Consent to Release form.
6. Based on the information you provide, we will assess your eligibility for the program you are applying for.
Once you have been found eligible, we will point score your application.
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Page 2 of 9
Program Type
Check all programs to which you would like to apply. If you are unfamiliar with the programs, please read the information sheets
available on our website and in our office.
Community Housing: You may be provided with one of our units in Red Deer, Innisfail
or Sylvan Lake.
• Each applicant must have lived or worked in the area for a least three months.
• Each applicant must have dependent children.
• Each household must have less than $25,000.00 in assets (Not including household furnishings)
• Rent is based on 30% of each tenant’s gross household income (before deductions)
• NO PETS PERMITTED
Rent Supplement Program: You keep your current rental unit and we may
supplement a portion of your rent.
DIRECT RENT SUPPLEMENT (DRS) (if you check this program, please remember to provide a tenancy
agreement/lease). Shared accommodation and room and board are NOT eligible. Basement suites do not qualify
unless certification of a legal suit status is provided from the City/Town.
PRIVATE LANDLORD RENT SUPPLEMENT (PLRS)
Personal Information
(Primary Applicant) Last Name
First Name
Phone #
Date of Birth (M/D/Y)
Co-Applicant Last name
First Name
Phone #
Date of Birth (M/D/Y)
Current Address:
City:
Postal Code:
How long at this address?
Mailing Address if Different than
above:
City:
Postal Code:
Language Preferred
English ☐ French ☐ Other ☐
Are you a legal resident of Canada?
Yes ☐ No ☐
Ethnicity
Caucasian☐ Aboriginal ☐
Other ☐ ______________
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Page 3 of 9
Household Composition
List all persons who will be living with you
should your application be approved
(First Name, Last Name)
Relation to
Applicant
Birth date
MO/DAY/YEAR
Age Gender (M/F)
1. Are you expecting the number of people in your household to:
Increase? ☐ _______________ or Decrease? ☐ __________________
2. Have you ever received rent supplement or community housing from RDHA? Please provide the date of
your last payment. ______________________________________
3. Is there a custody agreement in place for any minor children? (please provide a brief summary of the
agreement) _______________________________________________________________
____________________________________________________________________________
4. Which best describes your current residence?
House Townhouse Shelter/Emergency Unit
Duplex 4/6 Multiplex Hotel
Apartment
5. Rooms in your present residence:
# of bedrooms: ____
6. Do you share your accommodation or a portion thereof with any person(s) NOT listed on this application?
Yes____ or No____ If Yes, how many? Adults: _____ Children: _____
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Page 4 of 9
7. How much do you pay in rent per month? $__________
8. Have you received a rental increase or rent incentive? Yes____ No____
If yes, what is the new rent and when will this change? _______________________________
9. If you do not pay rent, do you contribute financially? Yes____ No____
If yes, provide details____________________________________________________________
10. Which utilities do you pay for (Check all that apply)
Heat Electricity Water/Sewer
11. Do you have to give one (1) months’ notice prior to moving? Yes____ No____
Term of Lease: _____________ Lease Expiry Date: ______________________
12. Have you been given an eviction notice? Yes____ No____
If you have been given a “NOTICE TO VACATE”, please submit a copy of the notice stating the
reason for the eviction.
13. Do you have a pet(s)? Yes____ No____
If yes what kind and how many? __________________________________________________
14. Do you require a wheelchair accessible suit? Yes____ No____
15. Does your house meet housing and safety standards? Yes____ No____
Please give examples (mould, no heat)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
16. Check all that apply to you and your household. Please provide documentation where
appropriate.
____ 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.
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Page 5 of 9
____ Fleeing family or other violence/abuse.
____ Homeless or at risk of homelessness.
____ Living in a group home.
____ In bankruptcy or have filed a consumer proposal
____ Are you a Housing First Graduate? Year Completed ___________
17. Please feel free to describe your present circumstances and any information you would like
RDHA to be aware of.
Assets
List the value of the following assets that are applicable or state N/A if not applicable.
Type of Asset
Total Value
Bank Account - Savings
$
Bank Account - Chequing
$
Bank Account - Other
$
Equity in Real Estate
$
Stocks, Bonds, Mutual Funds, etc.
$
Other Assets
$
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Page 6 of 9
Does anyone in your household:
Own/Lease a
vehicle
Yes-Lease
Yes-Own
No
Equity:
$_______
Value:
$______
Monthly Payment
$_______
Year, Make and Model:
Is there a 2
nd
vehicle in
your
household?
Yes-Lease
Yes-Own
No
Equity:
$_______
Value:
$______
Monthly Payment
$________
Year, Make and Model:
Income
List all current sources of income (monthly gross amounts) for everyone:
Source of Income
Received per Month
Name(s) of Recipients(s)
(list all members who get this
source of income)
Alberta Seniors Benefit (ASB)
AISH
Alberta Child Benefit (ACB)
Alberta Family Employment Tax Credit
(AFETC)
Band and/or Treaty Funding
Canadian Pension Plan (CPP)
Child Support (including section 7)
Company/Group Pensions
Canada Child Benefit (CCB)
Disability Benefit
Employment Insurance
Foreign Country Income
Government Family Support (i.e. kinship,
foster)
GST
Income Support/Social Assistance
Old Age Security (OAS)/
Guaranteed Income Supplement (GIS)
Partner/Spousal Support
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Page 7 of 9
Registered Retirement Income Fund (RIFFs)
Resettlement Assistance (RAP)
Self-Employment (Statement of Business
Activities)
Student Loans/Grants
Support from Family
Tips
Workers Compensation Board (WCB)
Working Income Tax Benefit (WITB)
Other
Employment
Note: All information regarding your family’s income must be complete and accurate. Provide details
of current employment held in the last 12 months. (Begin with the most recent employer).
Head of Household: Name___________________________________
Employed By:
Company & Address
Dates Employed
FROM TO
Hours
Per Week
Rate
Per Hour
Earnings
Per
WEEK MONTH
Total
Earned
References & Contacts
Emergency Contact
Name:
Relation:
Home #
Cell#:
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Page 8 of 9
Current Landlord
Name:
Phone#
Would this landlord provide a good reference? Yes____ No____ If no, why?
________________________________________________________________________________
Reasons for move:
Declaration, Waiver and Release Form
I understand that this application does not constitute an agreement on the part of Red Deer Housing
Authority, or its agents, to provide me with rental accommodation. I further acknowledge the right of Red
Deer Housing Authority at any time prior to the execution and delivery of a lease hereby applied for, to
withdraw, revoke or cancel, without penalty or liability for damage otherwise, any acceptance or approval of
this application previously made or given.
I/We ______________________________________________authorize Red Deer Housing Authority to
make any inquiries to verify the facts contained herein by any method deemed necessary, being fully aware
that discovery of any false statement shall cancel any further consideration of my application.
I further understand that it is my responsibility to contact the Red Deer Housing Authority in writing of any
changes in family composition, source of income, gross income assets, employment, and change of address or
any household changes should they occur.
I further understand that it is my responsibility to contact the Red Deer Housing Authority within Six
Months if applying and at least every six months thereafter and that failure to do so will result in the
cancellation of my application and the need to reapply.
_______________________________ _______________________________
Signature of Applicant #1 Signature of Applicant #2
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The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Page 9 of 9
OFFICE USE ONLY
STATUTORY DECLARATION
Dominion of Canada )
Province of Alberta ) In the matter of this application for dwelling accommodation/subsidy
To wit:
I/We, ____________________________of the __________ of ________________in the Province of Alberta, do solemnly
declare as follows:
1. I am the applicant named on the said application
2. That the statement made by me in the said application are complete and true in all respects
And I make this solemn Declaration conscientiously believing it to be true and knowing it is of the same forc
e and
ef
fect as if made under oath and by virtue of the “Canadian Evidence Act”.
Declared before me at the City of Red Deer, in The Province of Alberta, this _______day of________, 20_______.
____________________________ _____________________ ______________________
A Commissioner for Oaths in and For the Signature of Applicant Signature of Applicant
Province of Alberta
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Completed 18 July 2020

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