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Newell Housing Association
Application - Community Housing / Subsidy
* Are required fields
Contact Information
*Applicants Full Name:
(LAST) (First)
*Email Address
Home Phone:
Cell Phone:
Work Phone:
Post Office Box:
Street Address:
Apartment #:
City / Town:
Province:
Postal Code:
Household Information
Landlord's Name (if renting):
Phone #:
Rental Cost ($):
Utilities Included?:
Yes
No
Tenant Insurance?:
Yes
No
List all persons living in the household including yourself:
(Use one line per individual and leave a space between sections)
Full Name
(Last First Middle)
Sex
(M/F)
Date of Birth
(Year/Month/Day)
Age
Relationship / Title
(ie. Head of Household,Spouse,child)
Social Insurance #
Vehicle Year, Make and Model
License Plate #
Value
Monthly Payment
Own/Lease/Finance
Purchase Date
Please list all assets:
Type of Asset
Total Value
Bank Account – Savings
Bank Account - Chequing
Equity in Real Estate
Guaranteed Investment Certificates (GIC)
Mutual Funds
Registered Retirement Savings Plan (RRSP)
Savings Certificate
Stocks or Bonds
Please list all sources of income for household members 15 years of age and older:
Source of Income
Start Date
End Date
Total Gross Monthly Income
Tax Credits
Goods and Services Tax (GST)
Canada Child Tax Benefit (CCTB)
Alberta Family Employment Tax Credit (AFETC)
Government
Alberta Adult Health Benefit (AAHB) - $1/month
Assured Income for the Severely Handicapped (AISH)
Employment Insurance (EI)
Income Support (SFI)
Worker’s Compensation (WCB)
Canada Pension Plan
Disability
Orphan/Widow/Widower
Employment
Employer #1
(Name Address Phone)
Employer #2
(Name Address Phone)
Employer #3
(Name Address Phone)
Senior Benefits
Alberta Seniors Benefit
Company Pension
Canada Pension Plan (CPP)
Old Age Security/Guaranteed Income Supplement
Misc.
Child Support
Spousal Support/Allowance/Alimony
Other
(please specify):
Are you expecting?
Yes
No If Yes, when is your due date?
Is any member of your family physically handicapped?
Yes
No
Do you require a handicapped unit?
Yes
No
Do you have a pet?
Yes
No If yes, what kind(s) and how many of each?
If you want to move, what are the reasons?
If you have been given a ‘Notice to Vacate’ or ‘Eviction Notice’ please submit a copy to the office.
Please feel free to describe your present accommodation and any information you would like the Newell Housing Association to be aware of. This space is provided for you to explain your reasons for wanting to move into Community Housing or requesting subsidy and will assist us in the approval of your application.
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