Kingsway Sierra Housing Application Form

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Kingsway Sierra’s Mission is to provide affordable and well-managed, non-market, residential accommodations for persons who are at the commencement of tenancy are homeless or at risk of being homeless.

One Bedroom Suitable for Couples
Only Bachelors suitable for Singles

Date *
1. Applicant Information
Applicant Information *
2. Contact Information
2.1 Home Address
Street *
City *
Province *
Postal Code *
2.2 Mailing Address
Street *
City *
Province *
Postal Code *
2.3 Other
Home Phone *
Work Phone
Message Phone *
Email *
Contact Person (Optional)
Contact Person Phone
3. Household Information
List yourself first, then list all other house members *
Do all the people listed live with you all the time right now *
Please provide the name of the person(s) and number of days per week they live with you *
Do you expect the number of people living with you to change in the next 12 months? (e.g. pregnancy, family joining, family leaving, a child in care) *

Please explain and provide the expected date of household size change. *
Do you or anyone in your household identify as being an Aboriginal person of Canada? *
Please select the option that best describe your aboriginal identity *
4. Residency History
Please provide information on your last three (3) landlords.
Have you or any members of your household ever lived in subsidized housing?
Provide the following information for all previous subsidized housing.
Is there money owing due to a past tenancy?
How much is owing?
Is there a written repayment schedule in place?   
Please provide specifics here
Reason for debt

Note:  failure to declare past subsidized housing or debts owed to subsidized housing providers may result in the cancellation of your application.

5. Income and Asset Information
Is anyone in the household receiving income assistance from the Ministry of Housing and Social Development (formerly MEIA)?
Please complete the following for each person receiving assistance.
For all other income sources, list gross monthly income (before deductions) for everyone age 19 or older.
Total Gross Monthly Income for Household
Please tell us why there is no income for any adult (age 19 or older) with no income.
Note:  If any adult (age 19 or older) is a full-time student, attach proof of student status to the application.
Maximum file size: 32 MB
List the current value of assets held by you and family members of the household
Cash/Bank Balance
Stocks/Bonds/Term Deposits
Other Assets
Residential Real Estate
Other Real Estate Holdings
Note:  Proof of income and assets must be sent in with the application.  See the enclosed checklist for details.
Maximum file size: 32 MB
6. Current Accommodation
Do you;
How much is your rent payment?
Is this
Is heat included in the rent?
How many bedrooms does your household have? 
Please describe your current living arrangements
Please describe
Do you have a bathroom?
Do you have a kitchen?
Have you received a legal notice to end the tenancy?
Yes, what date do you have to move by?
Note: Attach a copy of the notice to end tenancy to the application. This notice must be the Residential Tenancy Branch’s Notice to End Tenancy Form.
Maximum file size: 32 MB
If you are NOT under notice to move, please tell us why you want to move.
7.  Health and Mobility Information
Do you or any household members have any mobility issues, health conditions or disabilities that we should be aware of? *
Do you or any members of your household have restrictions with stairs?
How many?
Do you or any members of your household use a
Who use it?
Is it used inside your home?
Is it used in the kitchen?
Is it used in the bathroom?
Can you and your household members access and function in all rooms in your current housing?
Please explain
Please describe any special requirements or features that you may need in your housing related to your mobility or health condition
Do you currently receive home support?
Number of hours per week
Who are the agencies providing home support?
8.  Housing Preferences/Choices
Do you or anyone in your household smoke in your home?
Do you have any pets?
How many?
Provide the following information for all household pets.
Tell us where you would like to live.
There are more people applying for housing than vacant units. Therefore, the time to find housing can be very long. To increase the chances of being offered a place to live, you might want to select a number of buildings or areas. However, please note that if you refuse two (2) offers of housing, your application will be cancelled. For that reason, you must be sure that you are prepared to live in any of the buildings or areas you list.

NOTE:  A maximum of two (2) offers of housing will be made.  If two offers are refused, your file will be cancelled.  Please make sure you are willing to live anywhere listed above.

Additional Information about you and your family that will help us understand your needs and serve you better:
Signed by
Date and time
Signed by
Date and time