BC Housing Rent Supplement Application

Supplement Request

Date of Request:*

Referring Agent:

Organization:

Phone Number:

Email:

Client Information

First & Middle Name:*

Last Name:*

Phone Number:*

Birth Date:*

Street Address:*

Apt, Suite, Bldg. (optional)

City:*

Province*---British Columbia

Postal Code*

Country*---Canada

Is this a new tenancy?*YesNo

Tenancy Start Date:*

Monthly Rental Amount:*

Gender:*MaleFemaleTransgender-FemaleTransgender-MaleOtherTwo-SpiritNon-binary

Aboriginal:*YesNo

Family Status:*SingleCoupleFamily (If yes, please fill in next entry)

Family Status (If family, please enter total number of individuals):

Monthly Income Amount:*

Source of Income:*NONEEMPLOYMENTEMPLOYMENT INSURANCE (EI)BASIC INCOME ASSISTANCE (IA)CANADA PENSION PLAN (CPP)CANADA PENSION PLAN – DISABILITY (CPP-D)OLD AGE SECURITY (OAS)GUARANTEED INCOME SUPPLEMENT (GIS)SAFERBCH RENTAL ASSISTANCE PROGRAM (RAP)CHILD TAX BENEFITINCOME ASSISTANCE - PERSONS WITH PERSISTANT MULTIPLE BARRIERS (PPMB)INCOME ASSISTANCE – PERSONS WITH DISABILTY (PWD)

OTHER SOURCE OF INCOME: (If OTHER - you MUST provide details here for your application to be considered)*

Have you received any rent supplement funding before?*YesNo

If yes (previous question), from where?CMHAKFSNow CanadaOther (If yes, please include more information in the field below):

Source of previous rent supplement funding: If OTHER, please provide details here

Previous rent supplement funding: On which date?

Check Those That Apply For Client

SelectIDENTIFIES AS ABORIGINALVICTIM OF VIOLENCELEAVING CORRECTIONAL SYSTEMLEAVING HEALTH CARE SYSTEMYOUTH AT RISKOTHER (If yes, please include more information in the field below)

Check those that apply: (If OTHER, please provide details here)

Type of Supplement Requested

Select*ONE-TIME CRISISMONTHLY RENT SUPPLEMENT (CONSIDERATION FOR EXTENSIONS WILL BE DETERMINED UPON REVIEW)

Please Describe

The situation & need pertaining to rent supplement request:*

How you plan to stabilize your housing situation after the supplement. (Ex: Income assistance will be approved so I can pay the rent)*

Has the client attempted to access funds elsewhere? Please explain:*

Landlord/ Billing Information

First & Middle Name:*

Last Name:*

Street Address:*

Apt, Suite, Bldg. (optional)

City:*

State / Province / Region*

Postal Code*

Country*

Phone Number:*

Rental Name (Hotel/ Building)*

Description of Rental*APARTMENT IN MARKET HOUSINGHOTEL/ ROOMING HOUSEROOM IN A HOUSESECONDARY SUITERECOVERY/TREATMENTCAMPSITESOCIAL HOUSING/SUPPORTED HOUSINGOTHER (If yes, please include more information in the field below)

Description of Rental: (If OTHER, please provide details here)

Other Supports Involved

Probation/ Parole

Mental Health Support

Alcohol & Drug Support

Family Physician

Psychiatrist

Other

Client Consent & Authorization

Service Provider Name:*

is seeking your consent for the following purposes:

Your consent to collect your personal information into the computer system we use.

• This will help us meet your needs and connect you with appropriate support services.

Your consent to share your personal information with our funder, BC Housing.

• BC Housing is responsible for hosting the computer system we use to help manage our services.
• BC Housing will use the information in the system, at an aggregate level, to help improve services and funding.

Your consent to migrate your personal information from the current computer system we use to the new one we will be using in the future.

Your consent to share your personal information with other service providers using the system.

• The new computer system we will be using in the future will allow for some data sharing.
• If you require services from another service provider, authorized staff will be able to access your personal information to improve the consistency and quality of services provided to you.

If you are accompanied by your children who are under the age of 19, we will also need to collect personal information about them. This is to ensure that information about families using services is recorded accurately.

Your consent to share limited non-identifying information with Employment and Social Development Canada.

• They will use this data to help create a national picture of the scope of homelessness in Canada.

If you choose not to sign this document, services will still be provided to you, except in regard to rent supplements. If your service provider has rent supplements, you will need to sign this consent form to be considered for and to receive a rent supplement (for accounting purposes).

Digital Signature

Signature of Client to Indicate ConsentI consent to the release of this information

Name of Client:*

Date of Consent:*

Attach Documents

Please attach any supporting documents. Acceptable file types for upload: .png, .jpg, .pdf, .doc, .docx, .xls

File Upload:

[anr_nocaptcha g-recaptcha-response]

Δ