APPLICANTLast name: _____________________________________________ First name: __________________________________________

Date of birth: ___ / ___ / ___ Sex: r F r M Language: r French r EnglishYY MM DD

(PLEASE PRINT) _________________________________

1

LOW-RENT HOUSING APPLICATION

FOR YOUR APPLICATION TO BE CONSIDERED, YOU MUST:1. 3 ANSWER ALL QUESTIONS.

2. 3 SIGN THE FORM.

3. 3 PROVIDE THE FOLLOWING: - A photocopy of your lease.- A signed photocopy of the provincial income tax return for the previous year and

the relevant tax slips or a detailed notice of assessment.- A photocopy of proof of school attendance (for current students aged 18 or over).- Other relevant documents.

PLEASE SUBMIT ALL DOCUMENTS REQUESTED AND SIGN THE APPLICATION.OTHERWISE, WE’LL BE REQUIRED TO RETURN YOUR APPLICATION.

YY MM DD

1 CURRENT ADDRESS

Address: ___________________________________________________________________________________________________

Apt: ____________ City: ________________________________________________________ Postal code: ________________

☎ Home: _____ ______ - _______ Cell: _____ ______ - _______ ☎ Work: _____ ______ - _______ Extension ______

Email address: __________________________________________________ Social Insurance Number: _______ _______ _______

When did you move here? ___ / ___ / ___ If you’ve been at this address for less than two years, complete Section 2.

2 PREVIOUS ADDRESSES If you've been at your address for less than two years, complete this section.

_______________________________ __________________ __________________ From ___ / ___ / ___ to ___ / ___ / ___

_______________________________ __________________ __________________ From ___ / ___ / ___ to ___ / ___ / ___Address City Postal code YY MM DD YY MM DD

If you need more space for previous addresses, attach an extra page.Address City Postal code YY MM DD YY MM DD

3 CONTACTS

___________________________________ ____________________ ____________________

___________________________________ ____________________ ____________________Name Tel. Relationship to you

Name two people who speak either French or English whom we can call if unable to reach you.

Name Tel. Relationship to you

4 THE MEMBERS OF YOUR HOUSEHOLD List all members you’re applying for, including yourself.

2* In the event of shared custody, indicate the % of time the child is in your care. Continued on page 3

A. APPLICANT LAST NAME (at birth) FIRST NAME DATE OF BIRTH

SEX AGE CIVIL STATUS RELATIONSHIP TO YOU r Fr M

FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________

APPLICANT

2

r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)

YY MM DD

YY MM DD

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

SEX AGE CIVIL STATUS RELATIONSHIP TO YOU r Fr M

FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________

SPOUSEr Single r Married r Common-law spouse r Separated r Divorced r Widow(er)

YY MM DD

YY MM DD

C. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH

SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________

r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)

YY MM DD

YY MM DD

D. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH

SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________

r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)

YY MM DD

YY MM DD

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

SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________

r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)

YY MM DD

YY MM DD

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

SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________

r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)

YY MM DD

YY MM DD

3

TENANT r- Number of rooms? ______________

- Rent (plus heat and electricity)? $ __________

- Do you have a cotenant? YES r NO r(other than the people named in this application)

- Portion of rent paid by the cotenant? $ _________________

6 TYPE OF HOUSING What floor do you live on? ______________ Is there an elevator in the building? YES r NO r

Please complete the section that applies to you:

LODGER r- With family or friends r

- In a rooming house r

- In an assisted living facility r

- Other (please specify)__________________________ r

- Monthly cost of room $ ____________________________

OWNER r

- How many rooms are there? ________

- Property assessment** $ _____________

- Mortgage balance** $ ______________

- Mortgage payment including taxes** $ _________________

- If you are renting out one or more rooms,how much do you receive per month?

$ _____________________________ **Attach copies of supporting documents.

Ever been evicted fromsubsidized housing?YES r NO r

HAVE YOU OR ANY MEMBER OF YOUR HOUSEHOLD:

Ever skipped out on subsidized housing without informing the landlord?YES r NO r

Any debts to a subsidized housing landlord? YES r NO r

G. OTHER HOUSEHOLD MEMBERS LAST NAME (at birth) FIRST NAME DATE OF BIRTH

SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________

r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)

YY MM DD

YY MM DD

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

SEX AGE SHARED CUSTODY* CIVIL STATUS RELATIONSHIP TO YOU r Fr M %FULL-TIME STUDENT CANADIAN CITIZEN PERMANENT RESIDENT ARRIVAL DATE IN CANADA COUNTRY OF BIRTHYES r NO r YES r NO r YES r NO r ______________________________

r Single r Married r Common-law spouse r Separated r Divorced r Widow(er)

YY MM DD

YY MM DD

5 DO OTHER PEOPLE NOT LISTED HEREIN ALSO LIVE WITH YOU? YES r NO r

If so, specify who: _____________________________________________________________________________________________

7 HAVE YOU OR A MEMBER OF YOUR HOUSEHOLD EVER LIVED IN LOW-RENT HOUSING BEFORE? YES r NO r

If so, please specify who: ___________________________________________________________________________________

Address of housing: _________________________________________________________________________________________

Date moved out: Reason for leaving: __________________________________________________________________ / ___ / ___YY MM DD

4

9 DO YOU, OR A MEMBER OF YOUR HOUSEHOLD, HAVE ANY ASSETS? IF SO, WHAT IS THE VALUE OF THOSE ASSETS?

Bank accounts

RRSP/RRIF

Savings bonds

Term deposits

Stocks

Other investments

Car Model

Year

Home, cottage

Other assets(excluding home furnishings)

APPLICANT

$ _______________

$ _______________

$ _______________

$ _______________

$ _______________

$ _______________

________________

________________

$ _______________

$ _______________

SPOUSE

$ _______________

$ _______________

$ _______________

$ _______________

$ _______________

$ _______________

________________

________________

$ _______________

$ _______________

OTHER HOUSEHOLD MEMBER

________________________

$ _______________

$ _______________

$ _______________

$ _______________

$ _______________

$ _______________

________________

________________

$ _______________

$ _______________

OTHER HOUSEHOLD MEMBER

________________________

$ _______________

$ _______________

$ _______________

$ _______________

$ _______________

$ _______________

________________

________________

$ _______________

$ _______________

NAME NAME

Earned income

Welfare

Old-age pension

Quebec pension plan

Other pensions

Employment insurance

CSST

SAAQ

Alimony received

Student scholarship

Interest income from investments

Other income (specify)

Enclose the supporting documents for this income.

8 INDICATE THE TOTAL INCOME FOR LAST YEAR OF EACH MEMBER OF YOUR HOUSEHOLD.

APPLICANT

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

SPOUSE

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

OTHER HOUSEHOLD MEMBER

________________________

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

OTHER HOUSEHOLD MEMBER

________________________

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

$__________ , ___

NAME NAME

Enclose the supporting documents for this income.

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g on

to

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site

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hm.qc.ca

IF Y

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6

12 INDICATE THE REASON(S) YOU’RE APPLYING FOR HOUSING

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

13 DECLARATION OF THE HEAD OF THE HOUSEHOLD

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 acknowledge that any false or incomplete statement regarding this form or anyattached documents may lead to one or more of the following consequences: rejection or cancellation of my application,downgrading or removal of my application from the eligibility list, loss of seniority, or withdrawal of a housing offer.

Signature: ____________________________________________________________________ Date : _____ / _____ / _____YY MM DD

4-20

2-1

(10-

2015

)

10 INFORMATION ON AUTONOMY

Is there a member of your household who has difficulty managing his or her basic needs alone? YES r NO r

Does someone provide regular care or support for that member of your household? YES r NO r

How many at-home care hours does this person receive per day? ___________________________________________

If you obtain a low-rent housing unit, will that person live with you? YES r NO r

If so, be sure to enter the person’s name in Section 4 on the list of members in your household.

11 SECTION RESERVED FOR DISABLED PEOPLEDoes anyone in your household have a significant and persistent physical locomotor disability? YES r NO rPlease provide: medical prescription and occupational therapist’s report.

If so, who? _______________________________________________________________________________________

Does this person use a wheelchair permanently? YES r NO r

If not, does he or she use a cane, walker, three-wheel scooter or another type of aid? Please specify. _________________

Does this person:

1. need help entering or exiting the building (because there is no access ramp orbecause the building’s outdoor layout doesn’t allow for easy manoeuvrability)? YES r NO r

2. need help entering or exiting the apartment? YES r NO r

3. have trouble getting around the apartment? YES r NO r

4. How many stairs must the person climb to get to your apartment? ________________________________________