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eSign Disclosures and Consents
It is required by law to provide you with certain disclosures and information about the programs and services you may receive or access in connections with your relationship with us (‘Required Information’) Lethbridge Housing Authority. With your consent, we can deliver Required Information to you by a) displaying or delivering the Required Information electronically; and b) requesting that you print or download the Required Information and retain it for your records.
This notice contains important information that you are entitled to receive before you consent to electronic delivery of Required Information. Your consent also permits the general use of electronic records and electronic signatures in connection with the Required Information.
After you have read this information, if you agree to receive Required Information from us electronically, and if you agree to the general use of electronic records and electronic signatures in connection with our relationship, please click the ‘I ACCEPT’ button below.
Statement of electronic disclosures:
You may request to receive Required Information on paper, but if you do not consent to electronic delivery of Required Information, we cannot proceed with the acceptance and processing to create a relationship with you in connection to the programs and services until the Required Information is submitted.
If you consent to electronic delivery of Required Information, you may withdraw that consent at any time. However, if you withdraw your consent we will not be able to continue processing to create a relationship with you in connection to the programs and services.
If you consent to electronic disclosures, that consent applies to all Required Information we give you or receive from you in connection with our relationship and the associated notices, disclosures, and other documents.
You agree to print out or download Required Information when we advise you to do so and keep it for your records. If you are unable to print or download any Required Information, you may call us and request paper copies. If you need to update your e-mail address or other contact information with us, you may do so by calling us and requesting the necessary updates.
If you wish to withdraw your consent to electronic disclosures, you may do so by calling us and requesting withdrawal of consent. After consenting to receive and deliver Required Information electronically, you may request a paper copy of the Required Information by calling us.
If you do not have the required software and/or hardware, or if you do not wish to use electronic records and signatures for any other reason, you can request paper copies of the Required Information.
Your consent does not mean that we must provide the Required Information electronically. We may, at our option, deliver Required Information on paper. We may also require that certain communications from you be delivered to us on paper at a specified address.
By submitting my/our information for application for one or more Lethbridge Housing Authority Programs or Services I/We are notifying LHA of my/our interest, application DOES NOT ensure acceptance into the program or service. I/We understand that this application does not constitute an agreement on the part of Lethbridge Housing Authority or its agents to provide you with rental accommodation.
I/We further acknowledge the right of Lethbridge Housing Authority at any time prior to the execution and delivery of a lease hereby applied for, to withdraw, revoke, or cancel without penalty and liability for damage or otherwise, any acceptance or approval of this application previously made or given.
I/We hereby authorize you to make any inquiries you deem necessary to verify the facts contained herein by any method Lethbridge Housing Authority deems necessary, being fully aware that discovery of any false statements shall cancel any further consideration of any application.
I/We further agree that I/We am/are obligated to advise Lethbridge Housing Authority, in writing, of any changes in family composition, gross income, assets, employment or change of address, should they occur.
I/We have read the information about the use of electronic records, disclosures, notices, and e-mail, and consent to the use of electronic records for the delivery of Required Information in connection with our relationship. I have been able to view this information using my computer and software. I have an account with an internet service provider, and I am able to send e-mail and receive e-mail with hyperlinks to websites and attached files. I also consent to the use of electronic records and electronic signatures in place of written documents and handwritten signatures.
The information on this form is collected under the authority of the Alberta Housing Act and is in accordance with Alberta’s Freedom of Information and Protection of Privacy Act. This information will be used to determine and verify the client’s eligibility under Social Housing Accommodation Regulations. If you have any questions, you may contact Placements or the FOIP Coordinator at Lethbridge Housing Authority business office (403) 329-0556.
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Page 1 of 6
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Please attach copies of the following documents for verification (where applicable, limit of 5MB size per attachment):
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Most Current Notice of Assessment
(What Revenue Canada returns to you)
Contact Canada Revenue Agency at 1-800-959-8281 to request replacement documents OR log in to your CRA My Account and click “Proof of Income Statement” to view and print
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If you are currently employed, please provide your last 3 months of paystubs or a letter from your employer to verify employment.
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If you receive AISH or Social Assistance Benefits, please provide a copy of your Income Support Budget/Health Benefits Card with benefit amount.
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If you are receiving Employment Insurance (EI), please provide your EI Summary Report with documentation of benefits.
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If you are receiving pensions, please provide documentation by attaching your three (3) most recent bank statements.
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If you are receiving benefits through the Workers Compensation (WCB), please provide documentation.
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If you receive Child Support and/or Spousal Support, please provide documentation such as receipts, bank statements, maintenance enforcement agreements, or court order.
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If receive benefits throught the Alberta Adult Health Benefit, please provide your current card and copy of your approval/renewal letter.
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If you are a student at a post secondary institution, please provide your Student Finance "Notice of Assessment" along with expenses (Tuition, Books, Supplies), number of classes/courses, your program name, and your expected graduation date.
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If you receive Federal and or Provincial Benefits, please provide verification from the CRA (Canada Revenue Agency).
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A copy of your current Lease Agreement or a Rental Report
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Page 2 of 6
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Applicant & Household Information
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| Applicant Information |
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Name:
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Date of Birth:
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/
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/
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Age:
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Gender:
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Month
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Day
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Year
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Home Phone:
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Cell Phone:
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Work Phone:
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Current Address:
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City:
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Postal Code:
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Mailing Address:
(If different than current address)
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Status in Canada:
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Canadian Citizen
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Permanent Resident
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Landed Immigrant
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(If checked, provide Landed Immigrant papers)
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Marital Status:
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Single
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Married
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Common Law
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Separated
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Divorced
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Widowed/Widower
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Are you receiving benefits through the Alberta Adult Health Benefit?
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Yes No
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If a translator is required, please provide their information:
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Translator’s Name:
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Translator’s Phone Number:
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| Spouse/Co-Applicant Information (if applicable) |
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Name:
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Date of Birth:
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Age:
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Gender:
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Month
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Day
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Year
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Home Phone:
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Cell Phone:
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Work Phone:
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| Household Composition |
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In the chart below, enter the names of ALL persons, including yourself, who will be living in your household.
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Full Name:
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Relationship
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Birthdate
(Month/Day/Year)
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Age
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Gender
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Employer or School
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1.
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2.
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3.
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4.
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5.
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6.
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7.
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Do you, or members of your household, have a medical condition that could impact your need for housing?
(For example, is wheelchair accommodation a requirement?)
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Yes
No
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If yes, please explain:
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Please note that a medical form may be required to determine eligibility for Seniors Housing.
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Page 3 of 6
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Rental Information
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| Current Housing Information |
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Present Accommodation:
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Do you presently rent or own?
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Are utilities included in your rent amount?
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Are your utility bills up to date?
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Rent
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Own
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Yes
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No
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Yes
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No
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If no, check which utilities you pay for:
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Date Moved in:
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Number of Bedrooms:
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Rental Payment/Month:
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Have you given notice to vacate?
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/
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Month
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Day
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Year
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Have you received an eviction notice?
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Yes
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No
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If yes, for what date?
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Current Landlord Information:
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Are you sharing any part of your current dwelling with persons not applying on this application?
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Why do you wish to move?
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| Previous Housing Information |
| Previous Address: |
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City: |
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| Dates of Occupancy: |
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Previous Landlord Information
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Landlord Name
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Landlord Address
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(If Known)
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Landlord Phone
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Landlord Email
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Reason for Move:
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Page 4 of 6
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Current Income
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Other Income
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Provide the gross (before deductions) monthly income for all members of your household listed on this application.
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Source of income
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Applicant Monthly Amount
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Co-Applicant Monthly Amount
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Alberta Seniors Benefit (ASB)
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$
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$
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Assured Income for the Severely Handicapped (AISH)
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$
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$
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Canada Child Benefit (CCB) – Formerly called the Child Tax Benefit (CTB)
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$
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$
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Canada Pension Plan (CPP)
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$
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$
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Child Support
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$
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$
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Disability Benefit
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$
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$
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Employment
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$
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$
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Employment Insurance (EI)
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$
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$
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Income Support/Social Assistance (SA) through Alberta Works
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$
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$
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Investment Income (Interest)
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$
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$
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Old Age Security (OAS)/Guaranteed Income Supplement (GIS)
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$
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$
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Partner/Spousal Support
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$
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$
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Private Pensions or Annuities
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$
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$
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Rental Income (from Investment Properties)
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$
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$
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Resettlement Assistance Program (for Government Assisted Refugees)
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$
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$
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Self Employed
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$
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$
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Student Loans/Grants
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$
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$
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Support for Foster & Kinship Caregivers
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$
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$
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Support from Family
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$
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$
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Workers Compensation Board (WCB)
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$
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$
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Other (Please Specify)
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$
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$
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Assets
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Complete for all members of your household on this application.
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Assets
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Total Value for all Household Members 18+
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Present Value
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Mortgage
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Property Owned
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$
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$
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Cash/Money in Bank
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$
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Investment Income
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$
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Stocks & Bonds
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$
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Other (Please Specify)
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$
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Page 5 of 6
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Other Information
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Vehicle(s)
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Do you own a vehicle?
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Yes
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No
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Do you own more than one vehicle?
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Yes
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No
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If yes, how many vehicles do you own?
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Make
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Model
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Year
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Payment Each Month
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Estimated Value
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Vehicle One
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$
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$
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Vehicle Two
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$
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$
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Vehicle Three
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$
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$
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Pet(s)
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Do you currently have a pet?
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Yes
No
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Please note that only certain units allow pets. Approval for a pet in a Lethbridge Housing Unit is subject to the landlord as some of our rental properties do not allow pets
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If you currently own a pet, what kind?
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Support Worker Information (if applicable)
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Support Worker Name:
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Phone:
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Agency:
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Fax:
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Are you a Housing First Graduate?
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Yes
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No
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Page 6 of 6
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Additional Comments
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Please note any additional comments regarding your situation below. Please be as detailed as possible about your circumstances and why you are seeking assistance through Lethbridge Housing. Use this section to clarify anything on your application that needs further explanation.
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Additional Comments
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The following fields on page 2 are mandatory to proceed:
- Applicant – Name
- Applicant – Phone (at least one of Home, Work, or Cell)
Please ensure that the fields above are completed before pressing submit.
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