Page 1 of 6  
Please attach copies of the following documents for verification (where applicable):
Most Current T1 General Tax Return
What you submit to Revenue Canada when you do your taxes
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 are a student and your student funding is from Alberta Works Income Support, please provide a copy of the funding information.  
A copy of your current Lease Agreement or a Rental Report  
Page 2 of 6 Applicant & Household Information
Applicant Information
Name: Marital Status:
Date of Birth: / / Age: Gender: Single
  Month Day Year  
Home Phone: Cell Phone: Work Phone: Married
Current Address: Common Law
Mailing Address:
(If different than current address)
Status in Canada: If a translator is required, please provide their information below. Divorced
Canadian Citizen

Permanent Resident

Landed Immigrant
Translator’s Name: Widowed/Widower
Translator’s Phone Number: If separated, divorced, or common-law, please state length of time.
Have you received subsidized housing in the past? Yes No Preference of location to live:

If yes, where?  
If yes, when?  
Spouse/Co-Applicant Information (if applicable)
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
Age Gender Employer or School
Page 3 of 6 Rental Information
Current Housing Information
Do you presently rent or own? Present Accommodation:
Rent Own
House Private Rental Hotel Dorm Shelter
Homeless Institutional Social Housing Other
Date Moved in: Number of Bedrooms: Rental Payment/Month: Are utilities included in your rental Payment?
/ /   Yes   No
Month Day Year  
      If no, check which utilties you pay for:
Heat Electricity Water & Sewer
Current Landlord Information: Why do you wish to move?
Landlord Name:
Address (if known):
Relationship Breakdown
Have you signed a lease? Have you received an eviction notice? Have you given notice to vacate?
Yes No
If yes, when does your lease expire?
Yes No
If yes, for what date?
Yes No
If yes, for what date?
Are you sharing any part of your current dwelling with persons not applying on this application? No Yes
If yes, indicate the number of people other than those listed on this application: Adults Children
Previous Housing Information
Previous Address:
Dates of Occupancy: Would this landlord provide a good reference?
From To
  Month Day Year   Month Day Year
  Yes No  
  If no, why?
Previous Landlord Information Reason for Move
Landlord Name
Landlord Address  
(If Known)  
Landlord Phone  
Landlord Email  
Page 4 of 6 Current Income
Employment Income Enter the total amount for all household members on the application who are 18+.”
Employee’s Full Name Workplace Name & Address Workplace Phone Dates of Employment
(M/Y – M/Y)
Payment Information
Pay/Hour Salary
$ $
$ $
$ $
$ $
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 Child and Family Benefit (ACFB) $ $
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 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)
$ $
Page 5 of 6 Assets & Debts
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 $
Registered Retirement Savings Plan (RRSP) $
Other (Please Specify) $
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 $ $
Name of Creditor (Shaw, Visa, Direct Energy, etc.) Amount Presently Owing Amount in Arrears
(Overdue Payment)
$ $
$ $
$ $
Page 6 of 6 Other Information
Other Information
Do you currently have a pet?   Yes
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?
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?)
If yes, please explain:
Personal References (Not relatives)
Name: Name:
Phone: Phone:
Relationship: Relationship:
Social Worker Information (if applicable)
Social Worker Name: Phone:
Agency: Fax:
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