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3 PREVIOUS ADDRESSES (if you have lived at your current address for less than 2 years, complete this section)
_______________________________ __________________ __________________ From ___ / ___ / ___ to ___ / ___ / ___
_______________________________ __________________ __________________ From ___ / ___ / ___ to ___ / ___ / ___Address City Postal code YY MM DD
4 CONTACTS ___________________________________ ____________________ ____________________
___________________________________ ____________________ ____________________Last name and first name Tel. Relationship to you
Indicate the last name and first name of two people who speak French orEnglish and whom we can contact in case you can not be reached
Last name and first name Tel. Relationship to you
2 CURRENT ADDRESS
Street no. and name ___________________________________________________________________________________________
Apt.: ____________ City ______________________________________________________ Postal code _________________
Telephone at home: _____ ______ - _______ Cell: _____ ______ - _______ Work: _____ ______ - _______ Extension ________
Email: __________________________________________________ Social Insurance Number (optional): _______ _______ _______
Since when do you live at this address? ___ / ___ / ___ (if you have lived at this address for less than 2 years, complete section 3)
1
Address City Postal code
LOW-RENT HOUSING APPLICATION
✓ Make sure you are eligible before filling out the form. Read the leaflet Living in subsidized housing in Montreal
✓ Fill out all the sections, from 1 to 13
✓ Sign the form at section 15
✓ Include copies of the following documents: • your latest provincial detailed notice of assessment
OR last year’s tax return to Revenu Québec • last year’s tax statements (Relevé 1, relevé 5, T4, etc.)• lease AND notice of rent increase• proof of school attendance for all members of your
household who are 18 years and over and who are still in school
• all other documents requested in sections 7, 9, 10 and 12
✓ Send all documents by mail or bring them in person to Service d’accueil des demandes de logement et de référence 415, rue St-Antoine Ouest, bureau 202, Montréal (Québec) H2Z 1H8
✓ For further information:• Telephone: 514-868-5588, option 3• OMHM website: www.omhm.qc.ca/en/
PLEASE NOTE: This form will be returned to you, withoutbeing processed, if a section is incomplete or if a documentis missing.
Signing up for the OMHM’s waiting lists for low-rent housing or a rent subsidy (PSL)
MAKE SURE YOUR APPLICATION WILL BE PROCESSED:
SECTION RÉSERVÉEÀ L’OMHM
D _______________________________
M _______________________________
1 APPLICANTLast name: _____________________________________________ First name: __________________________________________
Date of birth: ___ / ___ / ___ Sex: ❒ F ❒ M Language: ❒ French ❒ EnglishYY MM DD
YY MM DD
YY MM DD
YY MM DDYY MM DD
5 MEMBERS OF YOUR HOUSEHOLD (People to be included in your application)
2*In case of shared custody, indicate the % of time your child is in your care. To be continued on page 3
A. APPLICANT LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE CIVIL STATUS ❒ F❒ M
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT BORN IN CANADA YES ❒ DATE OF ARRIVAL IN CANADA YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ IF NOT, COUNTRY OF ORIGIN
___________________________
APPLICANT
2
❒ Single ❒ Married ❒ Common-law partner ❒ Separated ❒ Divorced ❒ Widowed
YY MM DD
YY MM DD
C. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU❒ F❒ M %
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT BORN IN CANADA YES ❒ DATE OF ARRIVAL IN CANADA YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ IF NOT, COUNTRY OF ORIGIN
___________________________
❒ Single ❒ Married ❒ Common-law partner ❒ Separated ❒ Divorced ❒ Widowed
YY MM DD
B. SPOUSE LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE CIVIL STATUS RELATIONSHIP TO YOU❒ F❒ M
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT BORN IN CANADA YES ❒ DATE OF ARRIVAL IN CANADA YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ IF NOT, COUNTRY OF ORIGIN
___________________________
SPOUSE❒ Single ❒ Married ❒ Common-law partner ❒ Separated ❒ Divorced ❒ Widowed
YY MM DD
YY MM DD
YY MM DD
D. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU❒ F❒ M %
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT BORN IN CANADA YES ❒ DATE OF ARRIVAL IN CANADA YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ IF NOT, COUNTRY OF ORIGIN
___________________________
❒ Single ❒ Married ❒ Common-law partner ❒ Separated ❒ Divorced ❒ Widowed
YY MM DD
YY MM DD
E. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU❒ F❒ M %
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT BORN IN CANADA YES ❒ DATE OF ARRIVAL IN CANADA YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ IF NOT, COUNTRY OF ORIGIN
___________________________
❒ Single ❒ Married ❒ Common-law partner ❒ Separated ❒ Divorced ❒ Widowed
YY MM DD
YY MM DD
F. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU❒ F❒ M %
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT BORN IN CANADA YES ❒ DATE OF ARRIVAL IN CANADA YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ IF NOT, COUNTRY OF ORIGIN
___________________________
❒ Single ❒ Married ❒ Common-law partner ❒ Separated ❒ Divorced ❒ Widowed
YY MM DD
YY MM DD
3
TENANT ❒- Number of rooms? ____________________
- Monthly rent as per lease: ______________$Check included services❒ Heating ❒ Hot water ❒ Electricity❒ Other (specify): _____________________________
- Do you have a co-tenant YES ❒ NO ❒(other than the people listed in section 5)
- How much does the co-tenant pay per month? ______________________$
7 CURRENT TYPE OF HOUSING What floor do you live on? ______________ Is there an elevator in the building? YES ❒ NO ❒
FILL IN THE SECTION THAT APPLIES TO YOU:
BOARDER ❒- In the home of a family
member or a friend ❒
- In a boarding house ❒
- In a residence with services ❒
- Other (specify)__________________________ ❒
- Monthly cost of your room ____________________________ $
HOME OWNER ❒
- Number of rooms?_______________
- Property assessment** ____________ $
- Mortgage balance**______________ $
- Mortgage payment including taxes**_____________________________ $
- If you rent one or more rooms, how much do you receive per month?
_____________________________ $
6 DO OTHER PEOPLE LIVE WITH YOU RIGHT NOW, BUT ARE NOT LISTED IN SECTION 5? YES ❒ NO ❒
If YES, specify: ______________________________________________________________________________________________(last name, first name and relationship to you)
**Include copies of supporting documents
8 HAVE YOU OR A MEMBER OF YOUR HOUSEHOLD EVER LIVED IN SUBSIDIZED HOUSING BEFORE (LOW-RENT, PSL, etc.)? YES ❒ NO ❒
If YES, please indicate the last name and first name of the person: ______________________________________________________
Address of housing: _________________________________________________________________________________________
Date of departure: Reason for departure: ___________________________________________________________
ever been evicted fromsubsidized housing? YES ❒ NO ❒
HAVE YOU OR A MEMBER OF YOUR HOUSEHOLD:ever left subsidized housing without informing the landlord? YES ❒ NO ❒
a debt towards the landlord of subsidized housing?YES ❒ NO ❒
G. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU❒ F❒ M %
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT BORN IN CANADA YES ❒ DATE OF ARRIVAL IN CANADA YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ IF NOT, COUNTRY OF ORIGIN
___________________________
❒ Single ❒ Married ❒ Common-law partner ❒ Separated ❒ Divorced ❒ Widowed
YY MM DD
YY MM DD
H. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU❒ F❒ M %
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT BORN IN CANADA YES ❒ DATE OF ARRIVAL IN CANADA YES ❒ NO ❒ YES ❒ NO ❒ YES ❒ NO ❒ IF NOT, COUNTRY OF ORIGIN
___________________________
❒ Single ❒ Married ❒ Common-law partner ❒ Separated ❒ Divorced ❒ Widowed
YY MM DD
YY MM DD
___ / ___ / ___YY MM DD
4
10 INDICATE ANY ASSETS YOU OR A HOUSEHOLD MEMBER HAVE, AS WELL AS THEIR MARKET VALUE
Bank accounts
RRSP/RRIF
Savings bonds
Term deposits
Stocks
Other investments
Car Model
Year
House, cottage
Other assets (excluding home furnishings)
APPLICANT
_______________ $
_______________ $
_______________ $
_______________ $
_______________ $
_______________ $
________________
________________
_______________ $
_______________ $
SPOUSE
_______________ $
_______________ $
_______________ $
_______________ $
_______________ $
_______________ $
________________
________________
_______________ $
_______________ $
OTHER HOUSEHOLD MEMBER
________________________
_______________ $
_______________ $
_______________ $
_______________ $
_______________ $
_______________ $
________________
________________
_______________ $
_______________ $
OTHER HOUSEHOLD MEMBER
________________________
_______________ $
_______________ $
_______________ $
_______________ $
_______________ $
_______________ $
________________
________________
_______________ $
_______________ $
Last name and first name Last name and first name
Employment income
Social welfare
Old-age pension
Québec pension plan
Other pensions
Employment insurance
CSST
SAAQ
Alimony received
Student scholarship
Investment income
Other income (specify)
Include copies of supporting documents for each income.
9 FOR EACH MEMBER OF YOUR HOUSEHOLD, INDICATE ALL OF LAST YEAR’S SOURCES OF INCOME
APPLICANT
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
SPOUSE
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
OTHER HOUSEHOLD MEMBER
________________________
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
OTHER HOUSEHOLD MEMBER
________________________
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
__________ . ___ $
Last name and first name Last name and first name
Include copies of supporting documents for each asset.
Senn
evill
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50
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Sain
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S *
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tsic
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dato
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ervi
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5
5
This
map
sho
ws
the
terr
itorie
s w
here
the
OM
HM’s
low
-ren
t ho
usin
g un
its a
nd o
ther
sub
sidiz
ed a
part
men
ts a
re lo
cate
d. In
dica
tew
ith a
che
ck m
ark ✓
up t
o 2
terr
itorie
s (in
clud
ing,
if y
ou w
ish t
o do
so,
the
ter
ritor
y w
here
you
cur
rent
ly li
ve).
INDI
CATE
YOU
R TE
RRIT
ORY
CHOI
CES
If yo
u ar
e of
fere
d an
apa
rtm
ent
in t
hete
rrito
ry o
f yo
ur c
hoic
e an
d yo
u tu
rn i
tdo
wn,
you
r ap
plic
atio
n w
ill b
e ta
ken
off
the
wai
ting
lists
and
you
will
loo
se y
our
seni
ority
.Yo
u w
ill h
ave
to w
ait
one
year
befo
re s
ubm
ittin
g a
new
app
licat
ion.
For f
urth
er in
form
atio
n on
the
loca
tion
of o
ur lo
w-r
ent
hous
ing
proj
ects
, con
sult
the
OMHM
’s w
ebsit
e at
ww
w.o
mhm
.qc.
ca/e
n/ho
usin
g
S *
S *M
anoi
r Anj
ou (M
-AN
J)(F
ees
will
be
adde
d fo
r add
ition
al m
anda
tory
ser
vice
s)
Serie
z-vo
us
inté
ress
é à
rece
voir
une
subv
entio
n vo
uspe
rmet
tant
de
dem
eure
r dan
s vo
tre
loge
men
t ac
tuel
? OU
I ❒N
ON ❒
(Plu
sieur
s con
ditio
ns s'
appl
ique
nt)
Si o
ui, v
otre
inté
rêt
sera
insc
rit à
vot
re d
ossie
r.
!CA
NCE
LLAT
ION
OF
YOUR
APP
LICA
TION
Wou
ld
you
be
inte
rest
ed
in
rece
ivin
g a
rent
su
bsid
yal
low
ing
you
to s
tay
in y
our c
urre
nt a
part
men
t?
YES ❒
NO ❒
(Sev
eral
con
ditio
ns a
pply
)
If YE
S, y
our i
nter
est
will
be
note
d in
you
r file
.
If yo
u liv
e al
one,
wou
ld y
ou a
ccep
t to
live
in
a s
tudi
o ap
artm
ent?
YE
S ❒
NO ❒
Hous
ing
in t
his
terr
itory
is E
XCLU
SIVE
LYfo
rse
nior
s ag
ed 6
0 an
d ov
er
Terr
itory
bou
ndar
y
Met
ro li
ne
6
14 YOUR COMMENTS (optional)
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
15 DECLARATION OF THE APPLICANT
I solemnly declare that the information provided herein is accurate and complete. I authorize the OMHM to verify thisinformation as needed. I understand that this information is confidential and will be used only for the purposes of the OMHMand the Société d’habitation du Québec. I recognize that any false or incomplete statement made in this form or with regardsto any included document could result in one or several of these consequences for my application: rejection, cancellation,downgrading, withdrawal from eligibility lists, loss of initial seniority or withdrawal of a housing offer.
Signature: __________________________________________________________________ Date: _____ / _____ / _____YY MM DD4-
202-
2 (1
1-20
19)
11 INFORMATION ON AUTONOMYIs there a member of your household who has difficulty managing his or her basic needs alone? YES ❒ NO ❒
Does someone provide regular care or support for that member of your household? YES ❒ NO ❒
How many daily hours of care does this member of your household receive at home? ______________________________
If you obtain a low-rent housing unit or PSL unit, will this member of your household live with you? YES ❒ NO ❒
If YES, be sure to list this member of your household in section 5.
12 INFORMATION ON PEOPLE LIVING WITH A DISABILITYDoes a member of your household have a significant and persistent physical locomotor disability? YES ❒ NO ❒
If YES, indicate the name of this person: ___________________________________________________________________
If YES, include a copy of the medical prescription and detailed occupational therapist’s report.
Does this person use a wheelchair permanently? YES ❒ NO ❒
If NO, does this person use a cane, walker, three-wheel scooter or other type of aid? Specify: ___________________________
Please check if this person:- needs help entering and exiting the building (because there is no access ramp or
because the building’s outdoor layout doesn’t allow for easy access)? YES ❒ NO ❒
- needs help entering or exiting the apartment? YES ❒ NO ❒
- has trouble getting around the apartment? YES ❒ NO ❒
How many steps does this person need to climb up or down to enter your apartment? ________________________________
13 ADDITIONAL INFORMATION
If the OMHM offered you an apartment where smoking is prohibited, would you accept to live there? YES ❒ NO ❒Do you own any pets? YES ❒ NO ❒If YES, indicate how many _______cat(s) _______dog(s)_______others, specify: _____________________