1

LOW-RENT HOUSING APPLICATION(Please print)

APPLICANTLast name: ______________________________________ First name: _________________________________________

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

2 PREVIOUS ADDRESSES

_____________________________________________ __________________ From ___ / ___ / ___ to ___ / ___ / ___

_____________________________________________ __________________ From ___ / ___ / ___ to ___ / ___ / ___Address City

4 TYPE OF HOUSING

Do you? Rent r Board r Own your home r

YY MM DD

YY MM DD YY MM DD

3 CONTACTS

___________________________________ ____________________ ____________________

___________________________________ ____________________ ____________________Name Tel. Relationship to you

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

Name Tel. Relationship to you

File No. _________________________________

1 CURRENT ADDRESS

Address: __________________________________________________________________________________________________

Apt.: ____________ City: _______________________________________________________ Postal code: ________________

Pager: ( ) _______ - ________ Cell: ( ) _______ - ________ % Home: ( ) _______ - ________

% Work: ( ) _______ - ________ Extension ______ Email address: ____________________________________________

When did you first move here? ___ / ___ / ___

If you rent:- How many rooms do you have? _______________- Are there double rooms? yes r no r- What floor are you on? _______________- How much is your rent? $ ______________- Electricity included? yes r no r- Heating included? yes r no r- Rental taxes (water, garbage) $ ______________- Do you receive a housing allowance? yes r no r

If so, how much? $ ______________- Do you rent out any room

in your home? yes r no rIf so, how much do you receive a month? $ ______________

Address City

If you board, do you live:- In a private rooming house that contains

more than two rented rooms? r

- In a shelter? rName of shelter: _________________________

- In the home of a family (whether relatives or not) that contains one or two rented rooms? r

- In a public or private residence for seniors? r- In subsidized housing

(low-rent housing, co-op, rent supplement)? r- Which floor are you on? ___________________- Do you share your room

with anyone else? yes r no rIf so, how many people? _________________

If you’ve been at this address for less than two years, complete Section 2.

YY MM DD YY MM DD

Do you own your home? yes r no r

If so, include a photocopy of your last municipal tax bill.

If you need more space for previous addresses, attach an extra page.

5 THE MEMBERS OF YOUR HOUSEHOLD

c) Other householdmembers

b) Spouse

List all members you’re applying for, including yourself.LAST NAME FIRST DATE OF SEX AGE CIVIL STATUSAT BIRTH NAME BIRTH

a) Applicant___ / ___ / ___

YY MM DD

r F r M

r Single r Marriedr Divorced r Separatedr Widowr Common-law spouse

d)

e)

f)

g)

h)

___ / ___ / ___YY MM DD

r F r M

r Single r Marriedr Divorced r Separatedr Widowr Common-law spouse

___ / ___ / ___YY MM DD

r F r M

r Single r Marriedr Divorced r Separatedr Widowr Common-law spouse

___ / ___ / ___YY MM DD

r F r M

r Single r Marriedr Divorced r Separatedr Widowr Common-law spouse

___ / ___ / ___YY MM DD

r F r M

r Single r Marriedr Divorced r Separatedr Widowr Common-law spouse

___ / ___ / ___YY MM DD

r F r M

r Single r Marriedr Divorced r Separatedr Widowr Common-law spouse

___ / ___ / ___YY MM DD

r F r M

r Single r Marriedr Divorced r Separatedr Widowr Common-law spouse

___ / ___ / ___YY MM DD

r F r M

r Single r Marriedr Divorced r Separatedr Widowr Common-law spouse

2

5 THE MEMBERS OF YOUR HOUSEHOLD

c) Other householdmembers

b) Spouse

List all members you’re applying for, including yourself.RELATIONSHIP FULL-TIME CITIZENSHIP

TO YOU STUDENT ARRIVAL DATE IN CANADA

a) Applicant___ / ___ / ___AYY MM DDr YES

r NO

APPLICANT

SPOUSE

Canadian citizenr yes r No

Permanent residentr yes r No

Coutry of origin______________________

d)

e)

f)

g)

h)

___ / ___ / ___AYY MM DDr YES

r NO

Canadian citizenr yes r No

Permanent residentr yes r No

Coutry of origin______________________

___ / ___ / ___AYY MM DDr YES

r NO

Canadian citizenr yes r No

Permanent residentr yes r No

Coutry of origin______________________

___ / ___ / ___AYY MM DDr YES

r NO

Canadian citizenr yes r No

Permanent residentr yes r No

Coutry of origin______________________

___ / ___ / ___AYY MM DDr YES

r NO

Canadian citizenr yes r No

Permanent residentr yes r No

Coutry of origin______________________

___ / ___ / ___AYY MM DDr YES

r NO

Canadian citizenr yes r No

Permanent residentr yes r No

Coutry of origin______________________

___ / ___ / ___AYY MM DDr YES

r NO

Canadian citizenr yes r No

Permanent residentr yes r No

Coutry of origin______________________

___ / ___ / ___AYY MM DDr YES

r NO

Canadian citizenr yes r No

Permanent residentr yes r No

Coutry of origin______________________

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a) Demandeur b) Conjoint

Earned income No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Welfare No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Old-age pension No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Québec pension plan No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Other pensions No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Employment insurance No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

CSST No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

SAAQ No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Alimony received No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Student scholarship No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Other income (specify) No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

ENCLOSE THE SUPPORTING DOCUMENTS FOR THIS INCOME.

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

c) Other household member d) Other

Earned income No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Welfare No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Old-age pension No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Québec pension plan No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Other pensions No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Employment insurance No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

CSST No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

SAAQ No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Alimony received No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Student scholarship No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

Other income (specify) No r If yes, how much for the year: $ __________ No r If yes, how much for the year: $ __________

4

5

7 DO OTHER PEOPLE NOT LISTED HEREIN ALSO LIVE WITH YOU?

r Yes r NoIf so, specify who: ____________________________________________________________________________________________

____________________________________________________________________________________________________________

8 HAVE YOU OR A MEMBER OF YOUR HOUSEHOLD EVER LIVED IN LOW-RENT HOUSING BEFORE?

r Yes r NoIf so, specify who: _____________________________________________________________________________________________

Address of housing: ______________________________________________________________________________________

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

9 WHAT IS THE CASH VALUE OF YOUR ASSETS?

Applicant Spouse Other member

Bank accounts No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________RRSP/RRIF No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________Savings bonds No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________ Term deposits No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________ Stocks No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________ Other investments No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________Car No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________

model ____________ model ____________ model ____________year _____________ year _____________ year _____________

Home, cottage No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________ Other assets No r If yes: $ __________ No r If yes: $ __________ No r If yes: $ __________ (excluding home furnishings) Specify ________________ Specify ________________ Specify ________________

10 EVALUATE THE QUALITY OF YOUR CURRENT HOMESECTION RESERVED FOR DISABLED PEOPLEDoes anyone use a wheelchair? If so, who? ____________________________________________________

Does this person: yes no

1. Need help entering or exiting the building (because there is no access ramp or because the building’s outdoor layout doesn’t allow for easy manoeuvrability)? r r B1

2. Need help entering or exiting the home? r r B2

3. Have trouble getting around the building? r r B3

4. Have trouble getting around the home? r r B4

5. Have trouble using the bathroom sink, bathtub or toilet? r r B5

6. Have trouble using the kitchen sink, stove or refrigerator? r r B6

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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 or federal 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). - Your last rental tax bill (if applicable).- Your last Hydro-Québec bill (optional).- Other relevant documents.

Please submit all documents requested and sign the application.Otherwise, we’ll be required to return your application.

CHOOSE YOUR AREA (borough or city)

Senneville

Beaconsfield

Dollard-des-Ormeaux Pierrefonds — Roxboro

Kirkland

Dorval (72)

Pointe-Claire (70)

Sainte-Anne-de-Bellevue (65)

L’Île-Bizard —Sainte-Geneviève (66)

S*

S*

S*

S*

Île Dorval

Baie-d’Urfé

Which area do you want to live in?

The map opposite shows the areas where our housing projects are located. Check off the name of the area you wish to live in. You may choose up to two areas (including your own area).

If you turn down a home located in a borough of your preferences, your application will be cancelled for a one-year period.

If you live alone, would you agree to live in a studio apartment?Yes r No r

PierrefondsS*

For more details on where our housing projects are located, log on to our website:www.omhm.qc.ca

4-20

2-1

(04-

11)

7

= Area with housing for seniors only.

City or borough boundary

Metro line

* SCôte-Saint-Luc

Mont-Royal

Saint-Laurent (71)

Westmount (80)

Outremont (82)

Ville-Marie (30)

Saint-Léonard (84)

Sud-Ouest (47)

Montréal-Nord (83)

Anjou (85)

Rivière-des-Prairies —Pointe-aux-Trembles (52)

Mercier —Hochelaga-Maisonneuve (21)

Villeray — Saint-Michel —Parc-Extension (12)

Rosemont —La Petite-Patrie (14)

PlateauMont-Royal (31)

Ahuntsic — Cartierville (1)

Verdun (81)LaSalle (79)

Lachine (74)

Côte-des-Neiges —Notre-Dame-de-Grâce (40)

Habitations Jeanne-Mance (36JM)

Montréal-Est (86)S*

S*

BO

UL. RO

I-RENÉ

AV. RON

DEA

U

AV. CHAUMONT

AV. GEORGES

AV. DE LA VÉRENDRYE

AV. RHÉA

UM

EAV. G

UY

AV. MOUSSEAU

BOUL. CHÂTEAUNEUF

Habitations Manoir Anjou (85MA)(Residence with mandatory additional services)

Montréal-Ouest

Hampstead

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

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

____________________________________________________________________________________________________________

12 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 this information asneeded. I understand that this information is confidential and will be used only for the purposes of the OMHM and the Société d’habita-tion du Québec. I recognize that any false or incomplete statement could cause my application to be rejected or cancelled or a housingoffer to be withdrawn.

Signature: __________________________________________________________________ Date: ___ / ___ / ___YY MM DD