Eagle Valley Senior Citizens Housing Society

Eagle Valley Senior Citizens Housing Society THE HAVEN 1095 Shuswap Avenue Sicamous, British Columbia V0E 2V1 Phone (250) 836-2310

I/We hereby make application for housing accommodation in Eagle Valley Haven: 1. Bachelor Suite (for one person) □ Bedroom Suite (for two people) □

2. Name in full (print): ______Surname Given Name

3. Present Address ______Phone______

4. Social Insurance No. ______Date of Birth: ______Day Month Year

5. Marital Status: Single □ Widow □ Widower □ Separated □ Married with Spouse □ Name of Spouse: ______

6. Given NAME AND ADDRESS OF NEXT OF KIN – (or person to be notified in case of accident, sickness or death)

Name: ______Address: ______Phone: ______

7. Name of Doctor: ______Address of Doctor: ______

8. Have you any special needs, any major Disability, or Chronic Illness? (keep in mind NO Nursing Care, or Meal service are provided) If YES, please explain: ______9. Name and Address of Two Character References – NOT Relatives:

______Phone: ______Name Street Address, City, Province and Postal Code

10. Where have you lived the past ten years? Give dates and addresses: ______

______

of 3 February 26, 2013 Obligations:

A. You must be at least 55 years of age. B. The rent is due and payable on the 1st of each month. If not paid, a notice to vacate will be rendered. C. The rent will include stove, fridge, heat, water, cable TV and garbage collection. D. No other furniture will be provided. E. All House Rules in effect now or as they may be amended from time to time are to be strictly observed. F. Nursing Care is not available and should your health, or that of you spouse, become such that nursing care is required; you will be required to move out of the housing complex. G. The damage deposit and rent will be those in effect at time of rental of the unit. H. Tenancy Agreement to be executed by both parties upon acceptance by the Eagle Valley Senior Citizens’ Housing Society.

FINANCIAL STATEMENT This information is confidential Part One – Monthly Income Pensions Received – State exact amount of last cheque received. Note – if single, fill in left column only. If married and living with spouse fill in both columns.

Yourself Your Spouse

1. Old Age Security Pension -OR- $______$ ______Old Age Security and Federal Supplement Combined 2. Canada Pension $______$ ______3. Province of British Columbia G.A.I.N. or Income Supplement $______$ ______4. Other Pensions or Superannuation Such as DVA, War Widows, Annuities, $______$ ______Handicapped, Workers’ Compensation, etc. TOTAL MONTHLY INCOME $______$ ______

Part Two – Assets 1. Cash (includes bank balances) $ ______2. Canada Savings Bonds (face value) $ ______3. Other – Bonds or Stocks (face value) $ ______4. Property A – Which you own (current real estate value) $ ______B – Property sold and you hold a mortgage or an agreement for sale- State amount owing to you $ ______

TOTAL VALUE OF ASSETS $ ______NET VALUE OF ASSETS $ ______(NOTE: do not include car or household effects as assets)

of 3 February 26, 2013 Please tell us a bit about yourself (and your spouse, if applicable)

1. Do you have a medical condition(s) that will improve your situation by moving to the Haven? Medical proof may be required. If so, please describe (keep in mind NO nursing care or meals are provided) ______

2. Do you have access to services? Can you drive or walk to doctors’ office, stores and Credit Union in Sicamous?

______

3. Tell us about your present accommodations.

Are you presently living in a crowded situation? ______

Are your sanitary facilities adequate? Do you have hot and cold running water and indoor toilet? ______

Are your kitchen facilities adequate? Do you have a working fridge and stove? ______

Are you living with friends or family? ______

Are you living in temporary accommodations? Living in your car, tent, travel trailer, motel etc? ______

Do you presently spend more than 70% of your income for rent, heat & hydro? YES _____ NO _____

Do you presently spend more than 50% of your income for rent, heat & hydro? YES _____ NO _____

Please tell us of any other concerns or information that pertains to your situation.

______

I/We declare that the above financial statement is correct and can be verified, if required, by the Eagle Valley Senior Citizens Housing Society.

WITNESS______SIGNED ______

DATE ______

GENERAL: This is an APPLICATION ONLY and DOES NOT necessarily guarantee that the applicant will be given occupancy or accommodation in Eagle Valley Haven.

of 3 February 26, 2013