Form HSD3037 — Shelter Information
This form is used to provide the Ministry of Social Development with required rental information for your file. Applicants and recipients of income assistance, disability assistance or hardship assistance may use this form when requesting money to pay rent and/or security deposits.
Please complete the form by following the instructions and ensure you include your full name or the name of the primary person on your file. If you know your client file number (it begins with GA) include it in the space provided. You may also wish to provide your Social Insurance Number.
The form provides a blank rent receipt for your convenience, it can be used to provide proof you paid your rent.
This is not a tenancy agreement under the Residential Tenancy Act and is only used for administrative purposes by Housing and Social Development.
Return the completed form to your local employment and assistance office.
Ministry of Social
Development
SHELTER INFORMATION
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance Act and the Employment and Assistance for Persons with Disabilities Act. The collection, use and disclosure of personal information is subject to the provisions of the Freedom of Information and Protection of Privacy Act. Any questions about this information should be directed to your local Employment and Assistance Office.
RENTING OR INTENDING TO RENT AT THE FOLLOWING ADDRESS
MAILING ADDRESS (IF DIFFERENT)
START DATE (YYYY MMM DD) for rental of the room or rental unit
PLEASE COMPLETE EITHER A OR B:
(A) CLIENT’S PORTION OF RENTAL AMOUNT |
TOTAL RENT (IF SHARED) |
MARKET RENT (IF SUBSIDIZED) |
$ |
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PER MONTH |
$ |
PER MONTH |
$ |
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PER MONTH |
SECURITY DEPOSIT REQUIRED? |
CLIENT’S PORTION OF SECURITY DEPOSIT |
ARE UTILITIES INCLUDED IN THE RENTAL RATE? |
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YES |
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NO |
$ |
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YES |
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NO |
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NUMBER OF ADULTS AT GIVEN ADDRESS |
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NUMBER OF CHILDREN |
AT GIVEN |
ADDRESS |
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OR
(B) ROOM AND BOARD (MEALS INCLUDED)
$PER MONTH
Note: Cost of room and board should include costs associated with food, maintaining the room, pro-rated utilities cost, and pro-rated property tax.
NAME OF REGISTERED OWNER OF THE LAND (PLEASE PRINT)
NAME OF LANDLORD INCLUDING PROPERTY MANAGER, AGENT (IF DIFFERENT)
ADDRESS OF LANDLORD AND POSTAL CODE |
POSTAL CODE |
TELEPHONE NUMBER OF LANDLORD |
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LANDLORD’S SIGNATURE |
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DATE SIGNED (YYYY MMM DD) |
X
We require a rent receipt in addition to this form immediately upon payment of the first month's rent (if your rent is not paid directly to the landlord by MSD) . All information may be verified. A rent receipt is attached to this form for your convenience.
This form is for Ministry of Social Development information only and does NOT constitute a tenancy agreement under the Residential Tenancy Act.
Rent Receipt
Date:
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(YYYY MMM DD) |
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Received from: |
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For the month of: |
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Rent $ |
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Room and Board $ |
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Security Deposit $ |
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Landlord’s Signature |
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SD3037(10/06/16) |
ORIGINAL - FILE COPY - CLIENT |