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APPLICANTLast name: _____________________________________________ First name: __________________________________________
Date of birth: ___ / ___ / ___ Sex: r F r M Language: r French r EnglishYY MM DD
(PLEASE PRINT) _________________________________
1
LOW-RENT HOUSING APPLICATION
FOR YOUR APPLICATION TO BE CONSIDERED, YOU MUST:1. 3 ANSWER ALL QUESTIONS.
2. 3 SIGN THE FORM.
3. 3 PROVIDE THE FOLLOWING: - A photocopy of your lease.- A signed photocopy of the provincial income tax return for the previous year and
the relevant tax slips or a detailed notice of assessment.- A photocopy of proof of school attendance (for current students aged 18 or over).- Other relevant documents.
PLEASE SUBMIT ALL DOCUMENTS REQUESTED AND SIGN THE APPLICATION.OTHERWISE, WE’LL BE REQUIRED TO RETURN YOUR APPLICATION.
YY MM DD
1 CURRENT ADDRESS
Address: ___________________________________________________________________________________________________
Apt: ____________ City: ________________________________________________________ Postal code: ________________
☎ Home: _____ ______ - _______ Cell: _____ ______ - _______ ☎ Work: _____ ______ - _______ Extension ______
Email address: __________________________________________________ Social Insurance Number: _______ _______ _______
When did you move here? ___ / ___ / ___ If you’ve been at this address for less than two years, complete Section 2.
2 PREVIOUS ADDRESSES If you've been at your address for less than two years, complete this section.
_______________________________ __________________ __________________ From ___ / ___ / ___ to ___ / ___ / ___
_______________________________ __________________ __________________ From ___ / ___ / ___ to ___ / ___ / ___Address City Postal code YY MM DD YY MM DD
If you need more space for previous addresses, attach an extra page.Address City Postal code YY MM DD YY MM DD
3 CONTACTS
___________________________________ ____________________ ____________________
___________________________________ ____________________ ____________________Name Tel. Relationship to you
Name two people who speak either French or English whom we can call if unable to reach you.
Name Tel. Relationship to you
4 THE MEMBERS OF YOUR HOUSEHOLD List all members you’re applying for, including yourself.
2* In the event of shared custody, indicate the % of time the child is in your care. Continued on page 3
A. APPLICANT LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE CIVIL STATUS RELATIONSHIP TO YOU r Fr M
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________
APPLICANT
2
r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)
YY MM DD
YY MM DD
B. SPOUSE LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE CIVIL STATUS RELATIONSHIP TO YOU r Fr M
FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________
SPOUSEr Single r Married r Common-law spouse r Separated r Divorced r Widow(er)
YY MM DD
YY MM DD
C. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________
r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)
YY MM DD
YY MM DD
D. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________
r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)
YY MM DD
YY MM DD
E. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________
r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)
YY MM DD
YY MM DD
F. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________
r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)
YY MM DD
YY MM DD
3
TENANT r- Number of rooms? ______________
- Rent (plus heat and electricity)? $ __________
- Do you have a cotenant? YES r NO r(other than the people named in this application)
- Portion of rent paid by the cotenant? $ _________________
6 TYPE OF HOUSING What floor do you live on? ______________ Is there an elevator in the building? YES r NO r
Please complete the section that applies to you:
LODGER r- With family or friends r
- In a rooming house r
- In an assisted living facility r
- Other (please specify)__________________________ r
- Monthly cost of room $ ____________________________
OWNER r
- How many rooms are there? ________
- Property assessment** $ _____________
- Mortgage balance** $ ______________
- Mortgage payment including taxes** $ _________________
- If you are renting out one or more rooms,how much do you receive per month?
$ _____________________________ **Attach copies of supporting documents.
Ever been evicted fromsubsidized housing?YES r NO r
HAVE YOU OR ANY MEMBER OF YOUR HOUSEHOLD:
Ever skipped out on subsidized housing without informing the landlord?YES r NO r
Any debts to a subsidized housing landlord? YES r NO r
G. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________
r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)
YY MM DD
YY MM DD
H. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH
SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________
r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)
YY MM DD
YY MM DD
5 DO OTHER PEOPLE NOT LISTED HEREIN ALSO LIVE WITH YOU? YES r NO r
If so, specify who: _____________________________________________________________________________________________
7 HAVE YOU OR A MEMBER OF YOUR HOUSEHOLD EVER LIVED IN LOW-RENT HOUSING BEFORE? YES r NO r
If so, please specify who: ___________________________________________________________________________________
Address of housing: _________________________________________________________________________________________
Date moved out: Reason for leaving: __________________________________________________________________ / ___ / ___YY MM DD
4
9 DO YOU, OR A MEMBER OF YOUR HOUSEHOLD, HAVE ANY ASSETS? IF SO, WHAT IS THE VALUE OF THOSE ASSETS?
Bank accounts
RRSP/RRIF
Savings bonds
Term deposits
Stocks
Other investments
Car Model
Year
Home, cottage
Other assets(excluding home furnishings)
APPLICANT
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
________________
________________
$ _______________
$ _______________
SPOUSE
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
________________
________________
$ _______________
$ _______________
OTHER HOUSEHOLD MEMBER
________________________
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
________________
________________
$ _______________
$ _______________
OTHER HOUSEHOLD MEMBER
________________________
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
$ _______________
________________
________________
$ _______________
$ _______________
NAME NAME
Earned income
Welfare
Old-age pension
Quebec pension plan
Other pensions
Employment insurance
CSST
SAAQ
Alimony received
Student scholarship
Interest income from investments
Other income (specify)
Enclose the supporting documents for this income.
8 INDICATE THE TOTAL INCOME FOR LAST YEAR OF EACH MEMBER OF YOUR HOUSEHOLD.
APPLICANT
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
SPOUSE
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
OTHER HOUSEHOLD MEMBER
________________________
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
OTHER HOUSEHOLD MEMBER
________________________
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
$__________ , ___
NAME NAME
Enclose the supporting documents for this income.
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ION
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.
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N
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. COU
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AV. L
ION
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LX
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DELI
SLE
BOUL. GEORGES-VANIER
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RUE
TUPP
ER
RUE CHOMEDEY
RUE DU FORT
RUE SAINT-MARC
BOUL
EVAR
D RE
NÉ-
LÉVE
SQU
E O
.
Man
oir Ch
arles-
Duta
ud (C
-DUT)
(Fee
s will
be
adde
d fo
r ad
ditio
nal m
anda
tory
ser
vice
s)
Côte
-des
-Neige
s —
Not
re-D
ame-
de-G
râce
T90
Ville
-Mar
ie T13
5
5
The
map
sho
ws th
e ar
eas whe
re o
ur lo
w-r
ent an
d ot
her su
bsid
ized
hou
sing
pro
ject
s ar
e lo
cate
d. C
heck
off the
nam
e of
the
are
ayo
u wish
to li
ve in
. You
may
cho
ose
up to
two
area
s (in
clud
ing, if
you
whi
ch to
do so, y
our ow
n ar
ea).
CHOOSE YOUR
ARE
A
If yo
u tu
rn d
own
a ho
me
loca
ted
in a
boro
ugh
of yo
ur pr
efer
ence
s, yo
urap
plicat
ion
will
be
canc
elled
for
one
year
. Af
ter
this p
erio
d, t
he a
pplic
ant
mus
t re
gister
aga
in. S
uch
canc
ellatio
nm
eans
tha
t th
e ap
plicat
ion
lose
s its
seni
ority
.
For m
ore
deta
ils o
n whe
re o
ur h
ousing
pro
ject
s ar
e lo
cate
d, lo
g on
to
our web
site
: www.om
hm.qc.ca
IF Y
OU LIV
E AL
ONE, W
OULD
YOU A
GRE
E TO
LIV
E IN
A
STUDI
O A
PART
MEN
T?
YES
rNO r
S *
S *
6
12 INDICATE THE REASON(S) YOU’RE APPLYING FOR HOUSING
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
13 DECLARATION OF THE HEAD OF THE HOUSEHOLD
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 acknowledge that any false or incomplete statement regarding this form or anyattached documents may lead to one or more of the following consequences: rejection or cancellation of my application,downgrading or removal of my application from the eligibility list, loss of seniority, or withdrawal of a housing offer.
Signature: ____________________________________________________________________ Date : _____ / _____ / _____YY MM DD
4-20
2-1
(10-
2015
)
10 INFORMATION ON AUTONOMY
Is there a member of your household who has difficulty managing his or her basic needs alone? YES r NO r
Does someone provide regular care or support for that member of your household? YES r NO r
How many at-home care hours does this person receive per day? ___________________________________________
If you obtain a low-rent housing unit, will that person live with you? YES r NO r
If so, be sure to enter the person’s name in Section 4 on the list of members in your household.
11 SECTION RESERVED FOR DISABLED PEOPLEDoes anyone in your household have a significant and persistent physical locomotor disability? YES r NO rPlease provide: medical prescription and occupational therapist’s report.
If so, who? _______________________________________________________________________________________
Does this person use a wheelchair permanently? YES r NO r
If not, does he or she use a cane, walker, three-wheel scooter or another type of aid? Please specify. _________________
Does this person:
1. need help entering or exiting the building (because there is no access ramp orbecause the building’s outdoor layout doesn’t allow for easy manoeuvrability)? YES r NO r
2. need help entering or exiting the apartment? YES r NO r
3. have trouble getting around the apartment? YES r NO r
4. How many stairs must the person climb to get to your apartment? ________________________________________