Independent Living Registration Form

INDEPENDENT LIVING

REGISTRATION FORM

INDEPENDENT SENIORS’ APARTMENT BUILDING 59+

RENTAL APPLICATION

16%

1. Applicant

Please select your choice of apartment building, in order of preference. (Do not select the same building more than once.)

First Selection

Second Selection

Third Selection

Parking Required

Yes No

Title

Last Name

First Name

Street No.

Street Name

Apt. No.

City

Province

Postal Code

Area Code/Home Phone No.

Area Code/Work Phone No.

Status

Social Insurance No.

Date of Birth

Sex

Give Name of a Person we may contact if we cannot reach you or the co-applicant (and that can act as interpreter if required)

Telephone No.

2. Spouse/Co-Applicant

Title

Last Name

First Name

Street No.

Street Name

Apt. No.

City

Province

Postal Code

Area Code/Home Phone No.

Area Code/Work Phone No.

Status

Social Insurance No.

Date of Birth

Sex

3. Present Accommodation

Which of the Accommodation stated below, do you have now?

Are you or any person who lives with you:

Visually Impaired Wheelchair User Hearing Impaired

Do you have a lease?

Yes No

If yes,

Monthly Yearly

If yes, Expiry Date

Present Landlord's Name

Address

Telephone No.

How long have you lived at present address?

Average wait times up to 2-6 years for 1 and 2 Bedroom.

Bene i tempi di attesa medi 2-6 anni per 1 camera da letto e per 2 camera da letto..

4. Statement of Gross Annual Income and Assets

Please attach your recent Income Tax Notice of Assessment and proof of household income.

Note: Your application will be returned to you if a copy of your recent Income Tax Notice of Assessment is not attached.

List all Annual Income and Assets for you and all other persons who will live with you in the Rental Unit.

Employment (from all Sources)

Applicant

Co-Applicant

Canada Pension

Applicant

Co-Applicant

Old Age Security

Applicant

Co-Applicant

Supplements

Applicant

Co-Applicant

Foreign Pension

Applicant

Co-Applicant

General Welfare

Applicant

Co-Applicant

Other Income

Applicant

Co-Applicant

Total Applicant Income

Total Co-Applicant Income

4. Statement of Gross Annual Income and Assets - Continued

Asset Source - Combined for Applicant and Co-Applicant

Bank Account 1

Asset Value

Bank Account 2

Asset Value

Interest

Asset Value

Total Assets

Subject to the other terms of this Application, information is to be relied upon by us in any legal proceedings, or must otherwise be produced in accordance with relevant law. Subject to the approval of your application in compliance with all the terms and condition, your name will be placed to our waiting list and we will contact you upon the availability.

APPLICANT'S ACKNOWLEDGEMENT

The undersigned acknowledges that I.C.B.S.A.C. – C.A.B.C. is not a nursing home and that to be accepted as a tenant and to remain a tenant the undersigned must be able to either: (i) manage on her/his own and be in good health or (ii) make arrangements satisfactory to I.C.B.S.A.C. – C.A.B.C. to receive all appropriate support services from a service agency in the community. Tenants are responsible to care for their personal needs and if the time should come that any resident: (i) is not able to care for her/his personal needs, or (ii) has not made arrangements satisfactory to I.C.B.S.A.C. – C.A.B.C. to receive all appropriate support services from a service agency in the community, then it shall be necessary for such resident to find accommodation elsewhere and vacate the premises.

INFORMATION CONSENT

The undersigned consents to I.C.B.S.A.C. – C.A.B.C. obtaining such information as may be deemed necessary at any time in connection with the undersigned in respect of her/his application for the above premises being applied for herein and for any renewal or extension thereof. The undersigned also consents to the disclosure of any information concerning the undersigned and the sharing or exchange of information concerning the undersigned, with and to: (i) any credit reporting agency or to any person to whom the undersigned has or proposed to have financial relations and to I.C.B.S.A.C. – C.A.B.C. obtaining a credit report concerning the undersigned and/or (ii) any physician or other health care professional. The undersigned agrees to provide to I.C.B.S.A.C. – C.A.B.C. satisfactory evidence of age, health, income and Canadian Residency. The undersigned further agrees to submit to I.C.B.S.A.C. – C.A.B.C. forthwith, a certificate of health executed by his/her doctor in the form required by I.C.B.S.A.C. – C.A.B.C.

ADDITIONAL FORMS

Download, print and have a physician complete the Physician Medical Report, below. Note: Your application will not be accepted if the Physician Medical Report is not completed and submitted to the Management Office by mail, email, fax or in person.

By Mail/In Person:

Email:

Fax:

Review the Rules and Regulations of the Rented Premises document below, for your reference.

Physician Medical Report

Rules and Regulations of the Rented Premises

Date

Applicant Electronic Signature:

Co-Applicant Electronic Signature:

I hereby declare, that all of the information I have provided is complete and correct.