Page 1 of 6  
Please attach copies of the following documents for verification (where applicable, limit of 5MB size per attachment):
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
 
If you are currently employed, please provide your last 3 months of paystubs or a letter from your employer to verify employment.  
If you receive AISH or Social Assistance Benefits, please provide a copy of your Income Support Budget/Health Benefits Card with benefit amount.  
If you are receiving Employment Insurance (EI), please provide your EI Summary Report with documentation of benefits.  
If you are receiving pensions, please provide documentation by attaching your three (3) most recent bank statements.  
If you are receiving benefits through the Workers Compensation (WCB), please provide documentation.  
If you receive Child Support and/or Spousal Support, please provide documentation such as receipts, bank statements, maintenance enforcement agreements, or court order.  
If receive benefits throught the Alberta Adult Health Benefit, please provide your current card and copy of your approval/renewal letter.  
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.  
If you receive Federal and or Provincial Benefits, please provide verification from the CRA (Canada Revenue Agency).  
A copy of your current Lease Agreement or a Rental Report  
 
Page 2 of 6 Applicant & Household Information
Applicant Information
Name:
Date of Birth: / /   Age: Gender:
  Month Day Year  
Home Phone: Cell Phone: Work Phone:
Current Address: City: Postal Code: Mailing Address:
(If different than current address)
Status in Canada: Canadian Citizen Permanent Resident Landed Immigrant
  (If checked, provide Landed Immigrant papers)
Marital Status:
Single Married Common Law Separated Divorced Widowed/Widower
Are you receiving benefits through the Alberta Adult Health Benefit?
Yes   No
If a translator is required, please provide their information:
Translator’s Name: Translator’s Phone Number:
 
Spouse/Co-Applicant Information (if applicable)
Name:
Date of Birth: / / Age: Gender:
  Month Day Year  
Home Phone: Cell Phone: Work Phone:
 
Household Composition
In the chart below, enter the names of ALL persons, including yourself, who will be living in your household.
Full Name: Relationship Birthdate
(Month/Day/Year)
Age Gender Employer or School
1.
2.
3.
4.
5.
6.
7.
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?)
  Yes
  No
If yes, please explain:
Please note that a medical form may be required to determine eligibility for Seniors Housing.
 
Page 3 of 6 Rental Information
Current Housing Information
Present Accommodation:
House Private Rental Hotel Dorm Shelter
Homeless Institutional Social Housing Other
Do you presently rent or own? Are utilities included in your rent amount? Are your utility bills up to date?
Rent Own Yes No Yes No
If no, check which utilities you pay for:
Heat Electricity Water & Sewer
Date Moved in: Number of Bedrooms: Rental Payment/Month: Have you given notice to vacate?
/ /  
Yes No
If yes, for what date?
Month Day Year  
Have you received an eviction notice? Yes No
If yes, for what date?
Current Landlord Information: Are you sharing any part of your current dwelling with persons not applying on this application? Why do you wish to move?
Landlord Name:
Address (if known):
Phone:
Email:
No Yes
If yes, indicate the number of people other than those listed on this application:
Adults
Children
Financial
Overcrowded
Relationship Breakdown
Domestic Violence
Other
 
Do not wish to move
 
Previous Housing Information
Previous Address: City:
Dates of Occupancy:
From To
  Month Day Year   Month Day Year
Previous Landlord Information  
Landlord Name Landlord Address
(If Known)  
Landlord Phone Landlord Email
Reason for Move:
 
Page 4 of 6 Current Income
 
Other Income Provide the gross (before deductions) monthly income for all members of your household listed on this application.
Source of income Applicant Monthly Amount Co-Applicant Monthly Amount
Alberta Seniors Benefit (ASB) $ $
Assured Income for the Severely Handicapped (AISH) $ $
Canada Child Benefit (CCB) – Formerly called the Child Tax Benefit (CTB) $ $
Canada Pension Plan (CPP) $ $
Child Support $ $
Disability Benefit $ $
Employment $ $
Employment Insurance (EI) $ $
Income Support/Social Assistance (SA) through Alberta Works $ $
Investment Income (Interest) $ $
Old Age Security (OAS)/Guaranteed Income Supplement (GIS) $ $
Partner/Spousal Support $ $
Private Pensions or Annuities $ $
Rental Income (from Investment Properties) $ $
Resettlement Assistance Program (for Government Assisted Refugees) $ $
Self Employed $ $
Student Loans/Grants $ $
Support for Foster & Kinship Caregivers $ $
Support from Family $ $
Workers Compensation Board (WCB) $ $
Other (Please Specify)
$ $
Assets Complete for all members of your household on this application.
Assets Total Value for all Household Members 18+
Present Value Mortgage
Property Owned $ $
Cash/Money in Bank $
Investment Income $
Stocks & Bonds $
Other (Please Specify) $
 
Page 5 of 6 Other Information
 
Vehicle(s)  
Do you own a vehicle? Yes No Do you own more than one vehicle? Yes No If yes, how many vehicles do you own?
  Make Model Year Payment Each Month Estimated Value
Vehicle One $ $
Vehicle Two $ $
Vehicle Three $ $
Pet(s)
Do you currently have a pet?   Yes
  No
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
If you currently own a pet, what kind?
Support Worker Information (if applicable)
Support Worker Name: Phone:
Agency: Fax:
Are you a Housing First Graduate? Yes No
 
Page 6 of 6 Additional Comments
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.
Additional Comments
 
 
  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.