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): ______
SurnameGiven 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: ______
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
______Phone: ______
Name Street Address, City, Province and Postal Code
10.Where have you lived the past ten years? Give dates and addresses: ______
______
______
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 areto 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 EagleValley 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)
Please tell us a bit about yourself (and your spouse, if applicable)
- 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)
______
- Do you have access to services? Can you drive or walk to doctors’ office, stores and Credit Union in Sicamous?
______
- 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 ______
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.
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February 26, 2013