Western RegionalHousing Authority

It is important to ensure that all sections of your app/icatk’n are completed by you andreturned to the office including all documentation required.

Applicant selection is based on the date received. The wait time will depend generally onthree factors:

(1) the receipt of your information,(2) the availability of units in the areas of choice and(3) the number of applications ahead of yours on the waiting list. When yourapplication reaches the top of the waitlist, an interview will be arranged, at whichtime a landlord reference check will be completed. If we are unable to contactyou, your application will be cancelled

Rents are established on an individual basis using a percentage of the total householdincome received from all sources.

jj applications must be accompanied by verification of your monthly income in the form ofa cheque stub, bank book or statement, letter from your employer as well as a copy of anymaintenance order for child support etc. We also require a copy of your most recentIncome Tax Summary page or Notice of Assessment.

FAMILYUNITAPPLICANTS ONLY: You are required to complete and forward theattached Nova Scotia Power Confirmation sheet to the fax number indicated to confirmyour ability to get power in your own name prior to being approved for a housing waitlist.

Note: if there is more than one, both leaseholders must complete and j.gn the NSPCform.

S The majority of family units consist of three bedrooms, living room, kitchen andbath. They contain a fridge, stove and hookup for a washer and dryer.

• The majority of senior units consist of one bedroom, living room and kitchenette,bath and storage room. They contain a fridge and stove and there are laundry facilities inevery complex.

Thank you for applying. Should you have any additional questions, do not hesitate to callour office between the hours of 8:30 am and 4:30 pm, Monday through Friday.

25 Kentucky Court New Minas, NS, E34N 4N1Phone: 902.681.3179 toll Free: 1 800.441.0447 Fax: 902.681 0806

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Section 1 - Applicant

Nova Scotia Coordinated Access Housing Application

Primary DetailsSalutation El Mr. El Mrs. El Ms.Last Name

First NameMaiden Name

Marital Status El Single El DivorcedDate of Birth (MM/DD/YYYY)Social Insurance Number (SIN)

Student El Yes El NoStatus in Canada El Canadian Citizen

El Other Specify if Other

Priority Access (This pertains to all household members listed on the application)

El I/We are victim(s) of family abuse. If you checked any of the checkboxes,El I/We are required to live in a location close to life sustaining health sevices please specify details:

El I/We currently occupy inadequate housing which poses an immediate healthand/or safety risk

Current AddressStreet No. and Name Apt. No.City

Province Postal Code Country

Mailing Address (if different than current address)Street No. and Name Apt. No.City

Province Postal Code Country

Telephone NumbersHome E-Mail Address

Work Can we safely contact you at your mailing address and home phone El Yes El Nonumber?Cellular

Present Accommodationlome Information El Own

1onthly Housing Expenses: Please include monthly mortgage payment or monthly rent andweraqe monthly electricity, water, heating fuel and taxes, as applicable.

- $

andlord Name Telephone Number

ength of Tenancy (Months)

-lave you received an eviction notice? El Yes El No Eviction Dateviction Reason

‘ersons to contact in your absencegame Relationship Telephone Number

If No, where can we contact you?

El Rent El Temporary El Homeless El Shelter El Boarder

Current Landlord Information (Please leave this section blank it you reside in you own home or are homeless)

El Miss

Middle Name

El Common LawSex

El Married

El MaleEl Widowed

El FemaleEl Other

Name of School

El Landed Immigrant

Nova Scotia Coordinated Access Housing Application

Section 2 - Co-Applicants I Other Members

Leaseholder El Yes El No Relationship to Applicant

Salutation El Mr. El Mrs. El Ms. El Miss

Last Name

First Name Middle Name

Marital Status El Single El Divorced El Common Law El Married El Widowed El Other

Date of Birth (MM/DD/YYYY) Sex El Male El Female

Social Insurance Number (SIN)

Student El Yes El No Name of School

Status in Canada El Canadian Citizen El Landed Immigrant

El Other Specify if Other

Leaseholder El Yes El No Relationship to Applicant

Salutation El Mr. El Mrs. El Ms. El Miss

Last Name

First Name Middle Name

Marital Status El Single El Divorced El Common Law El Married El Widowed El Other

Date of Birth (MM/DD/YYYY) Sex El Male El Female

Social Insurance Number (SIN)

Student El Yes El No Name of School

Status in Canada El Canadian Citizen El Landed rmmigrant

El Other Specify if Other

Leaseholder El Yes El No Relationship to Applicant

Salutation El Mr. El Mrs. El Ms. El Miss

Last Name

First Name Middle Name

Marital Status El Single El Divorced El Common Law El Married El Widowed El Other

Date of Birth (MM/DD/YYYY) Sex El Male El Female

Social Insurance Number (SIN)

Student El Yes El No Name of School

Status in Canada El Canadian Citizen El Landed Immigrant

El Other Specify if Other

Leaseholder [Yes El No ReIationsrp to Appilcant

Salutation El Mr. El Mrs. El Ms. El Miss

Last Name

First Name Middle Name

Marital Status El Single El Divorced El Common Law El Married El Widowed El Other

Date of Birth (MM/DD/YYYY) Sex El Male El Female

Social Insurance Number (SIN)

Student El Yes El No Name of School

Status in Canada El Canadian Citizen El Landed Immigrant

El Other Specify if Other

Nova Scotia Coordinated Access Housing ApplicationSection 3 - Previous Tenancy Please specify previous 3 tenancies or previous tenancies up to 3 years

for Applicant and Co-Applicant(s), whichever is longer:

Have you ever been a tenant in:

Public Housing El Yes El No Rent Supplement El Yes El NoNon-Profit El Yes El No Other El Yes El NoCooperatives El Yes El No If Other, specify

Applicant/Co-Applicant Occupancy From (MM/YY)

Address Line 1 Occupancy To (MM/YY)

Address Line 2 Landlord Name

City Landlord Phone No.

Province, Postal Code

Country

Applicant/Co-Applicant Occupancy From (MM/YY)

Address Line 1 Occupancy To (MM/YY)

Address Line 2 Landlord Name

City Landlord Phone No.

Province, Postal Code

Country

Applicant/Co-Applicant Occupancy From (MM/YY)

Address Line 1 Occupancy To (MM/YY)

Address Line 2 Landlord Name

City Landlord Phone No.

Province, Postal Code

Country

Applicant/Co-Applicant Occupancy From (MM/YY)

Address Line 1 Occupancy To (MM/YY)

Address Line 2 Landlord Name

City Landlord Phone No.

Province, Postal Code

Country

pplicantCo-Applicant Occupancy From ( MM/YY)

ddress Line 1 Occupancy To (MM/YY)

ddress Line 2 Landlord Name

ity Landlord Phone No.

3rovince, Postal Code

:ountry

Nova Scotia Coordinated Access Housing Application

Section 4 - Income Statement of all MONTHLY income BEFORE deductions received by all persons/familymembers to live in the accommodation

Applicant Last Name ---->

Applicant_First_Name_---->

Income Categories $ Amount $ Amount $ Amount $ Amount

Alimony/Child_Support

Capital Gains

Canada Pension Plan Disability

Canada Pension Plan Other

Dividends

Employment Insurance

Employment Income

Foster Child Payments

Gratuities

Immigrant Sponsorship

Human Resource DevelopmentCanadaInterest

Old Age Security/Guar. IncomeSupp./Spouse_Allow.Other Country Social Security

Other Income

Other Pension

Rental Income

RRSP/RIF

Social Assistance

Student Loan

Workers Compensation

Veteran Pensions & Allowance

Total Income for member: $

Total Income for the household per month: $

Nova Scotia Coordinated Access Housing Application

Section 5 - Housing Preferences Note: Select unit size based on your family size. These preferences will determinethe properties that are suitable for your selection based on your requirements.Housing accommodations may not be available to meet all of your requirements.

Unit Size : ED Bachelor ED I. Bedroom ED 2 Bedroom ED 3 BedroomED 4 Bedroom ED S Bedroom ED 6 Bedroom

Resident Type:- Non Elderly (57 yrs

I/We want to live in a community for: ED Family ED Senior ED old or under)

Accessibility:

Is anyone in your household disabled? ED Yes ED No

I/We require one or more of the following: Wheel Chair Accessibility ED

Ground Floor due to inability to climb stairs EDParaplegic Unit / Modified Unit

Hearing Impaired Unit EDVisually Impaired Unit EDOther ED

If Other Specify:

Supportive Services Required:I/We are required to live in a location where essential support services are available: EDSpecify:

Do you currently have home support services? ED Yes ED No

Other Details:

Is anyone in the household a Single Parent? (This is voluntary information) ED Yes ED No

Is an additional child expected (baby,adoption,etc.) ? (This is voluntary information.This information will be used to determine your future housing requirements.) ED Yes ED No

If yes, Due Date (MM/DD/YYYY)

Do you own a house? ED Yes ED No

Do all household members reside in present accommodation? ED Yes ED No

if No provide information in notes box

Do you currently have a pet? (This is subject to Housing Authority Approval) ED Yes ED No

Do you require parking? ED Yes ED No

Nova Scotia Coordinated Access Housing Application

Declaration and Consent: Please read and sign this statement:

I/We declare that the information provided in the application form is correct and complete.

I/We understand that falsification of any or all information provided by me/us may be cause for thecancellation of the application.

I/We understand that it is my/our responsibility to advise the Housing Authority of any changes tothe information given in this application and to provide any supporting materials required formy/our application.

I/We authorize the Housing Authority or its representatives to make inquiries that are necessary toverify the information submitted in this application.

I/We authorize the Housing Authority to receive and exchange information with my/our current andprevious landlord(s).

Applicant’s Signature

Co-ApplicanttsSignature

Application Date

WESTERN REGIONAL HOUSING AUTHORITYFAMILY UNIT LOCATIONS

New Minas Middleton25 Kentucky Court PO. Box 1000New Minas, NS. Middleton, NS.B4N 4N1 BOS 1POTelephone: 9026813179 Telephone: 9028253481Toll Free: 1-800-4410447 Toll Free: 1800-564-3483

Please check (NJ) all areas where you would be interested in livingS NOTE! You willonly be placed on the waiting lists for the areas that you have indicated

HANTS COUNTY

Town of Windsor El Crossley CourtEl Underwood DriveEl O’Brien St.El Burgess Crescent

Upper Burlington El Hwy #215Centre Burlington El CheverieThree Mile Plains El Panuke Rd.

El Alexander St.El Denise Dr.El MacLeod Court

Bramber El Lantz Rd.Falmouth El Town Rd.

El Gabriel Rd.Mun. West Hants El Cameron Lake

El Highway 215, WaltonNewPort El Highway 14Curry’s Corner El Kendall Lane

KINGS COUNTY

Town of Berwick El Orchard St.El Robinson Dr.

Town of Kentville El Inglewood Dr.El Minas St.El Prospect St.El Sherry Ave.El Brooklyn St.El Cornwallis Cres,El Main St.

North Kentville El Mee Rd.El ApplecrestEl Beicher St.El Marjorie Dr.El Marie Court

Town of Wolfville El Cherry LaneEl Dale StreetEl Aldershot Rd.

KINGS COUNTY - cont’d...

Waterville

Canning

Aylesford

New Minas

CambridgeLakevifleCentreville

Avonport

Kingston

Greenwood

ANNAPOLIS COUNTY

C Rafuse Rd.C Highway #1

Thompson Rd.C Country Home Rd.C Cavelle St.C Hwy #358, Canning Mtn.C Summer St.C Cavelle TerraceC Black Hole Rd

C Kelly Dr.C Sandy CourtC Colonial CresentC Dow Rd.C Castleloma Dr.C Memory LaneC Old Ratchford Rd.C Hwy #221C Hwy #359C Rockwell Mtn. Rd.C Mary Ave.C Anthony Ave.C Bluff Rd.C West Brooklyn Mtn.C Lincoln St.C Bowiby Park Rd.C Park St.C Tufts Ave.C Pleasant St.C Spinney St.C Rocknotch Rd.

Deep BrookMiddleton

Granville FerryBncktonNictaux

LawrencetownCville, Lawrencetown

ton Corner, BrdgetownBeaconsfield, BridgetownCentrelea, BridgetownClementsport

C Dunn Rd.Meadow Lane

C Sunset Cres.C Commercial St.C Hoilow DriveC Granville Beach2 Hwy #1C Bonavista Dr.C Hwy #201C Fitch Rd.2 Inglisville Rd.

fvlorse Rd.C Inglewood Rd.C Hwy #201C Old Post Rd.

/Western Regional

/ Housing Authority

PET POLICY

Permission to keep a pet may be granted, subject to the “Pet Policy Rulesand Regulations”, to tenants who reside in a house or apartment that hasdirect access to the outside. Residents in other locations may bepermitted to keep a pet by reason of Special Need (ie. Seeing Eye dog).

All requests to have a pet must be in writing on the prescribed“Application for Permission to Keep a Pet Animal”. You will be notified inwriting if your application is approved. This permission is subject to the“Pet Policy Rules and Regulations” and may be withdrawn for failure tocomply with any of these rules. The Authority may also, at its solediscretion, withdraw permission to meet changing conditions.

RULES AND REGULATIONS:

A pet for the purpose of eligibility refers to “common household pets”such as a dog, cat or rabbit, which are usually kept for pleasure. Eachhousehold will only be permitted to have one pet (such as one cat or onedog) at a time.

RESTRICTIONS:

Reptiles, farm animals or animals that would be dangerous or frighteningto other tenants will not be permitted. No Pit Bulls, Rottweilers,Dobermans, German Shepherds, Mastiffs or cross breeds there of, will bepermitted. Pets must not be kept for breeding purposes.

EXCEPTIONS:

Permission will be given to those residents who require a special needsdog. A letter confirming official training for purpose of special needswill be required in these instances.

LICENSING:

The Pet shall be licensed according to applicable local bilaws, Ownersmay be required to provide evidence of this license.

25 Kentucky Court, New Minas, NS, 84N 4N1Phone: 902.681 3179 Toll Free: 1 800 441 0447 Fax: 902.681 0806

INOCULATIONS:

All pets shall be inoculated in accordance with provincial and municipallaws. Pet owners shall be required to provide proof of this whenrequested.

SANITARY STANDARDS:

It is the responsibility of the tenant to ensure that waste is cleaned upfrom the property on a regular basis. If a litter box is used, it must becleaned regularly to prevent odors.

RESTRAINT:

A pet shall be properly restrained and controlled while in any common orpublic area at the project. A pet shall not be allowed to run at large. Ifrepeated incidents of allowing a pet to roam or make unnecessary noiseare noted, the owner may be advised that the animal must be removedfrom the project.

REGISTRATION WITH THE AUTHORITY:

A tenant must make application to the Authority for permission to keep apet. A pet shall be registered with the Authority before it is brought tothe project. The following information will be required:

A. Proof of inoculation and licensing.B. Description (size, type, etc.).C. The name, address and telephone number of someone who will

look after the pet in the tenant’s absence.

EMERGENCY SITUATIONS:

If a pet is vicious, displays symptoms of severe illness or demonstratesother behavior that constitutes an immediate threat to the health orsafety of the tenants in general, the Authority shall have the petremoved from the property by whatever process it deems necessary. TheHousing Authority reserves the right to charge the tenant for any damagedone by the pet.

25 Kentucky Court, New Minas, NS, B4N 4N1

Phone 902 681 3179 Toll Free 1 800 441 0447 Fax 902 681 0806