low-rent housing application · 2020. 1. 13. · low-rent housing application make sure you are...

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 %


___________________________


YY MM DD

B. SPOUSE LAST NAME (at birth) FIRST NAME DATE OF BIRTH

SEX AGE CIVIL STATUS RELATIONSHIP TO YOU❒ F❒ M


___________________________

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



___________________________


YY MM DD

YY MM DD

E. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH



___________________________


YY MM DD

YY MM DD

F. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH



___________________________


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



___________________________


YY MM DD

YY MM DD

H. OTHER HOUSEHOLD MEMBER LAST NAME (at birth) FIRST NAME DATE OF BIRTH



___________________________


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

________________________

_______________ $

_______________ $

_______________ $

_______________ $

_______________ $

_______________ $

________________

________________

_______________ $

_______________ $


________________________

_______________ $

_______________ $

_______________ $

_______________ $

_______________ $

_______________ $

________________

________________

_______________ $

_______________ $

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

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $


________________________

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $


________________________

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

__________ . ___ $

Last name and first name Last name and first name

Include copies of supporting documents for each asset.

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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: _____________________

low-rent housing application · 2020. 1. 13. · low-rent housing application make sure you are...

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