The Haven

I/We hereby make application for housing accommodation in Eagle Valley Haven:

Suite Type: *Bachelor Suite (for one person)Bedroom Suite (for two people)

Full Name *

Present Address

Phone *

Date of Birth *

Marital Status *SeparatedMarried with Spouse

Name of Spouse

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

Name of Doctor

Address of Doctor

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:

Name and Address of Two Character References – NOT Relatives:

Name

Address

Phone

Name

Address

Phone

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

Obligations:

You must be at least 55 years of age.
The rent is due and payable on the 1^st of each month. If not paid, a notice to vacate will be rendered.
The rent will include heat, hot water, garbage collection and basic cable.
No other furniture or furnishings will be provided ( including curtains).
Damage deposit, first months’ rent and pet deposit (if applicable) will be required on the first day of when you take possession of the suite.
The rent will be reviewed on an annual basis and will be subject to an increase in line with the BC Government and BC Residential and Tenancy guidelines.
Smoking policy of the Eagle Valley Senior Citizens Housing Society does not allow smoking of cigarettes, cigars, e-cigarettes/vapes or cannabis in the units or porches, whether medicinal or not and must be used 6 meters away from all buildings or at designated smoking areas.
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. Please provide your three most recent bank statements and your latest income tax statement.

Old Age Security Pension -OR- Old Age Security and Federal Supplement Combined

Yourself

CAD

Your Spouse

CAD

Canada Pension

Yourself

CAD

Your Spouse

CAD

Province of British Columbia
G.A.I.N. or Income Supplement

Yourself

CAD

Your Spouse

CAD

Other Pensions or Superannuation
Such as DVA, War Widows, Annuities
Handicapped, Workers’ Compensation, etc.

Yourself

CAD

Your Spouse

CAD

TOTAL MONTHLY INCOME

Self Total

Spouse Total

Part Two – Assets (To compute Monthly Income from these – we take 1% of 1/12th of Total Assets)

1. Cash (includes bank balances)

USD

2. Canada Savings Bonds (face value)

USD

3. Other – Bonds or Stocks (face value)

USD

4. Property

A – Which you own (current real estate value)

USD

B – Property sold and you hold a mortgage or an agreement for sale- State amount owing to you

USD

TOTAL VALUE OF ASSETS

$

(NOTE: Do not include car or household effects as assets)

Please tell us a bit about yourself.

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 is 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?YesNo

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

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

Are you living with friends or family?YesNo

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

Do you presently spend more than 70% of your income for rent, heat & hydro? *YESNO

Do you presently spend more than 50% of your income for rent, heat & hydro? *YESNO

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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