Fraser East Housing Application

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EMAIL TO: info@frasereast.org

Rental Application

Application Date *

Name of Applicant *

How did you hear about this Ryder?

Contact Information

Current Street Address *

Phone *

Email Address *

Household Information

List yourself and other household members

Last Name *

First Name *

Additional household members

1 more2 more3 more

Last Name

First Name

Last Name

First Name

Last Name

First Name

Do you expect the number of people living with you to change during the next 12 months? (ex: pregnancy, family joining, family leaving, child in care) *yesno

Please explain change to household numbers and provide expected date of change

Are there one or more adults in your household that work? *YesNo

Has anyone in your household claimed bankruptcy? *YesNo

Has the bankruptcy been discharged?YesNo

Housing History

Please provide information on where you have lived for the past 5 years

Dates

Landlord Name

Landlord Phone

Reason for Leaving

Is there money owing due to a past tenancy?YesNo

How much is owed?

Has a payment plan been arranged?YesNo

Reason for debt and payment plan details

REFERENCE INFORMATION

First and last name *

Relationship *

Phone number *

Email Address *

Income and Asset Information

Is anyone in your household receiving income assistance from the Ministry of Social Development and Poverty Reduction?YesNo

How many people are receiving assistance?

Name of first person receiving assistance

Monthly amount of assistance

Assistance Category

Income Assistance (IA)Person with Disabilities (PWD)Person with Persistent Multiple Barriers (PPMB)

Name of second person receiving assistance

Monthly amount of assistance

Assistance Category

Income Assistance (IA)Person with Disabilities (PWD)Person with Persistent Multiple Barriers (PPMB)

Name of third person receiving assistance

Monthly amount of assistance

Assistance Category

Income Assistance (IA)Person with Disabilities (PWD)Person with Persistent Multiple Barriers (PPMB)

For all other income sources, list gross monthly income (before deductions) for everyone age 19 and older (proof of income and assets must be provided upon intake)r

Full Name

Income source

Gross monthly income

Add an additional income sourceYes (I have more income sources to enter)No (I'm done with income)

Full Name

Income source

Gross monthly income

Add an additional income sourceYes (I have more income sources to enter)No (I'm done with income)

Full Name

Income source

Gross monthly income

List the current value of assets held by you and members of the household

Cash/Bank Balance

RRSP's/Annuities

Stocks/Bonds/Terms

Residential Real Estate

Other Assets

Other Real Estate

How many vehicles does your household own?

Current Housing

Answers to the questions below will help Fraser-East to assess your current housing need

Do you currently rent? *YesNo

How much is your monthly rent payment?

Is heat included in the rent?YesNo

Do you have a bathroom?YesNo

Do you have a kitchen?YesNo

How many bedrooms does your current household have?

Please describe your current living arrangements

Have you received a legal notice to end tenancy?YesNo

What date do you have to move by?

Health and Mobility

To assist you with matching you to housing that best suits your needs, please complete the following questions

Do you or any member of your household have restrictions with stairs?YesNo

How many people have restrictions with stairs?

Do you or any member of your household use a wheelchair or scooter?YesNo

Is the wheelchair used inside your home?YesNo

Is the wheelchair used in the kitchen?YesNo

Can you and your household members access and function in all rooms in your current housing?YesNo

Please explain your answer

Other than mobility concerns, do you or any members of your household have a major health condition or disability?YesNo

Please give a description of the major health condition/dosability and the name of the household member

Does the health condition/disability affect your ability to function in your current housing?YesNo

Please describe any special requirements or features that you may need in your housing relating to your mobility or health conditions.

Housing Preferences

What size unit would be your first preference?Studio2 bedroom3 bedroom

If your first preference is not available, what would be your next choice?Studio2 bedroom3 bedroom

Do you have any pets?YesNo

How many total?

If you have a dog is it a certified service dog?YesNoI don't have a dog

Provide information about all of your household pets including pet type and breed (do not include certified service dogs)

Community Referrals

Please list the community referrals that would help you with your housing placement (employer, health professional, social worker, lawyer, friend, community agency etc.)

Name of referral *

Agency or relationship to you *

Email Address *

I have another referral to add

Name of referral *

Agency or relationship to you *

Email Address *

Community Living

We intend for our buildings to have a sense of community, which forms when tenants take care of their homes and form connections with neighbors. Would you be willing to give a bit of your time to help build a positive community environment in your building?YesNo

Do you have any experience with volunteer work?YesNo

Please provide details about your volunteer work

Would you like to be informed of volunteer opportunities in your building?YesNo

Do you have any ideas about how you could contribute to the community in your building?

Please do not fill in this field.

Fraser-East Affordable Housing Society acknowledges our agency provides services within the traditional, ancestral and unceded territory of the Stó:lō and Nlaka’pamux.

Contact

info@frasereast.org