Application – Dartmouth Housing – Non-Profit Housing in Dartmouth, Nova Scotia

Eligibility Checklist

Please read the following very carefully. If you answer YES to all of the following questions, you are eligible to make an application for affordable housing with Dartmouth Housing.

Must be 18 years of age or older – Primary applicant

Your household income from all sources must be within the minimum and maximum limits (including children 18 years of age or older) • Apartment (1BR – 2BR) – Min – $10,000/year Max- $ 25,000/year • House (3BR – 4BR) – Min – $22,000/year Max- $ 55,000/year

Must be able to provide the most current Canada Revenue Agency (CRA) Notice of Assessment for income verification for household members 18 years of age or older

Must not have ownership in any Real Estate (Residential/Commercial)

All rental balances owing from any landlord must be paid in full

Must provide proof of student status for children age 18 to 24 who are full-time students

Must not own a pet. Units do not accommodate pets

Must be able to open an account with NS Power and Halifax Water in the leaseholder(s) name

Housing Application Form

1. APPLICANT 1 PERSONAL DETAILS

Salutation

Mr.

Mrs.

Ms.

Miss

Last Name

First Name

Date of Birth

Social Insurance Number/SIN (optional)

Home Phone

Cell

Work

Email

Current Address Street

Apt. #

City

Postal Code

How long have you lived at your current address?

Previous address if less than 1 year

Name of your current landlord

Phone

Monthly Rent

Number of Current Bedrooms

Employer’s Name

Contact Name

Address

Phone

Term of Employment

Position Held

APPLICANT 2 PERSONAL DETAILS

Salutation

Mr.

Mrs.

Ms.

Miss

Last Name

First Name

Date of Birth

Social Insurance Number/SIN (optional)

Home Phone

Cell

Work

Email

Current Address Street

Apt. #

City

Postal Code

How long have you lived at your current address?

Previous address if less than 1 year

Name of your current landlord

Phone

Monthly Rent

Number of Current Bedrooms

Employer’s Name

Contact Name

Address

Phone

Term of Employment

Position Held

2. CURRENT HOUSING INFORMATION

Have you received an eviction notice?

Yes

No

If Yes, why?

Are you in a month to month or fixed term lease?

Month to Month

Fixed Term

If fixed term, when does your lease expire?

Have you ever been a tenant in Public, non-profit, or cooperative housing?

Yes

No

How did you hear about Dartmouth Housing?

Housing NS

Current Tenant

OtherOther

If Yes, which one?

Do you owe money for past tenancy with any landlord?

Yes

No

If Yes, how much is owing and is there a written payment schedule?

3. HOUSING NEEDS

Unit Size

1BR Apartment

2BR Apartment

3BR House

4BR House

Do you or any other applicant have a vehicle?

Yes

No

If Yes, how many?

Do you or any other applicant have a pet?

Yes

No

Do you or any other applicant require accessibility modifications?

Yes

No

If yes, please specify.

Do you expect the number of people living with you to change in the next 12 months? (e.g. pregnancy, family joining, family leaving, child in care, etc.)

Yes

No

If Yes, please explain with expected date of household size change

4. INCOME & ASSETS

For all household members 18 years of age or older please provide the most current CRA Notice of Assessment. For each applicant 18 years or older please provide monthly income amounts before deductions for the following categories:

Applicant 1

Applicant Last Name

Applicant First Name

Income Categories $ / Month

Alimony/Child Support

Capital Gains

Canada Pension Plan Disability

Canada Pension Plan Other

Dividends

Employment Insurance

Employment Income

Foster Child Payment

Gratuities

Immigration Sponsorship

Student Loan

Workers Compensation

Human Resource Development Canada

Veteran Pensions & Allowance

Interest

Old Age Security/Guar. Income Supp./Spouse Allowance

Other Country Social Security

Other Income

Other Pension

Rental Income

RRSP/RIF

Social Assistance

Total Income

Applicant 2

Applicant Last Name

Applicant First Name

Income Categories $ / Month

Alimony/Child Support

Capital Gains

Canada Pension Plan Disability

Canada Pension Plan Other

Dividends

Employment Insurance

Employment Income

Foster Child Payment

Gratuities

Immigration Sponsorship

Student Loan

Workers Compensation

Human Resource Development Canada

Veteran Pensions & Allowance

Interest

Old Age Security/Guar. Income Supp./Spouse Allowance

Other Country Social Security

Other Income

Other Pension

Rental Income

RRSP/RIF

Social Assistance

Total Income

Applicant 3

Applicant Last Name

Applicant First Name

Income Categories $ / Month

Alimony/Child Support

Capital Gains

Canada Pension Plan Disability

Canada Pension Plan Other

Dividends

Employment Insurance

Employment Income

Foster Child Payment

Gratuities

Immigration Sponsorship

Student Loan

Workers Compensation

Human Resource Development Canada

Veteran Pensions & Allowance

Interest

Old Age Security/Guar. Income Supp./Spouse Allowance

Other Country Social Security

Other Income

Other Pension

Rental Income

RRSP/RIF

Social Assistance

Total Income

Applicant 4

Applicant Last Name

Applicant First Name

Income Categories $ / Month

Alimony/Child Support

Capital Gains

Canada Pension Plan Disability

Canada Pension Plan Other

Dividends

Employment Insurance

Employment Income

Foster Child Payment

Gratuities

Immigration Sponsorship

Student Loan

Workers Compensation

Human Resource Development Canada

Veteran Pensions & Allowance

Interest

Old Age Security/Guar. Income Supp./Spouse Allowance

Other Country Social Security

Other Income

Other Pension

Rental Income

RRSP/RIF

Social Assistance

Total Income

Total income for the household per month: $

5. HOUSEHOLD COMPOSITION

List yourself on line 1 then all persons who will be living in the unit.

Full Name (Last/First)

Date of Birth

Relationship to Applicant

Type of Disability (if any)

Do They Live Full-Time with You Now?

Yes

No

If no, how many days per week?

Full Name (Last/First)

Date of Birth

Relationship to Applicant

Type of Disability (if any)

Do They Live Full-Time with You Now?

Yes

No

If no, how many days per week?

Full Name (Last/First)

Date of Birth

Relationship to Applicant

Type of Disability (if any)