RENT BANK FORM – Surrey, White Rock, Delta, Township and City of Langley Rent Bank

Surrey, White Rock, Delta, Township and City of Langley Rent Bank Form

- Step 1 of 3

PART ONE: YOUR INFORMATION

Applicant Type

Individual
Family

Do you have two pieces of ID?

You must have at least one piece of Photo ID

NAME AND CONTACT INFORMATION

First Name *

Last Name *

Phone *

Cell

Email *

Preferred Method of Communication

Phone
Email
Either

YOUR ADDRESS

Address *

City *

Province *

Postal Code

Adults in the Household

Number of Adults in the Household over the age of 18 years old

Children/Dependents

Number of Children/Dependents in the Household

Total People in the Household

Total Number of People in the Household

PERSONAL INFORMATION

Date of Birth *//

Legal Status

Please describe.

ie. International Student, Temporary Foreign Worker

Marital Status

PART TWO: INCOME AND FINANCES

INCOME

Checkboxes (check all that apply) *

Employed Full-Time
Employed Part-Time
Self-Employed
CERB Benefit
Worker's Compensation Benefits (WCB)
Employment Insurance (EI)
Child Tax Benefits
Tax Credits
Income Assistance (IA)
Persons with Disability (PWD)
Persons w/ Persistent Multiple Barriers (PPMB)
Pension(s)/ CPP / Old Age Security (OAS)
Child Support/ Alimony
CPP Disability Pension
Private/Work Disability Pension
Private/Work Retirement Pension

Your Total Monthly Income After Taxes

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

Number of Income Earners in Your Household

Total Household Monthly Income After Taxes

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

FINANCES

Please check all that apply

I have a bank account
I can provide 3 months of bank statements
Debts: I have credit card debt
Debts: I have payday loan debt
Debts: I have other loans
Debts: I have outstanding debt to a Rent Bank
I have recently declared bankruptcy

What is your monthly rent? *

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

What is the TOTAL of your monthly rent and expenses?

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

What is YOUR current debt?

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

What is your current household debt?

Includes all members of your household.

If your housing is currently subsidized, please identity which organization is providing the subsidy.

TELL US MORE ABOUT YOUR CURRENT SITUATION

What is Your Current Housing Emergency? (Check All that Apply) *

Written Eviction Notice
Already Evicted/Currently Homeless
Cannot make next month’s rent
Behind in Rent
Received Verbal Eviction Warning
Received Utilities Disconnection Notice
Utilities already disconnected
Behind in Utilities
Need Damage Deposit
Need 1st month’s rent
Pet Deposit

Please describe your current crisis or the reason for your application.

Max 150 words

What other sources of financial assistance have you sought? (Check All that Apply)

EI
CERB
WCB
Social Assistance
CPP
Family
Friends
Other

Please Describe.

What was the Result?

Applied, and Approved
Applied, but Waiting
Declined
Accessing Other Sources
Not Tried Other Sources

DETERMINING YOUR REQUEST

How much do you owe in rent (rental arrears)?

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

If you need a damage deposit or next month’s rent how much do you need?

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

If you require assistance with utilities, how much do you owe?

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

What is the total amount of assistance you need? *

Please round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)

SUBMITTING YOUR APPLICATION

I have read and agree to the Terms of Service Listed Below

Promise of Truth

I swear that all answers given on the Pre-Assessment and Application form I provided to the BC Rent Bank (“BCRB”) are true, the whole truth and nothing but the truth. I understand and acknowledge that any misrepresentation of my circumstances, financial or otherwise will lead to automatic ineligibility.

Consent

I have requested support from the BC Rent Bank program. I authorize my regional rent bank coordinator or representatives to represent me and advocate on my behalf in dealings with financial institutions, employers, landlords, utility companies and any other third party that my regional rent bank coordinator and/or staff deem necessary for the purpose of the BC Rent Bank program. I authorize those third parties to disclose to my regional rent bank coordinator and/or staff necessary personal information. If I am successful to receive the loan, I consent to receiving a follow up survey at 6 and 12 month periods by email, SMS, or phone call to assess the impact of the loan for program success measurement purposes.

Liability Release

I hold harmless and release from all liability the BC Rent Bank and any of its employees, partner agencies or funders for anything done or omitted to be done in the course of providing me services. I understand and acknowledge that BC Rent Bank cannot guarantee and is not responsible for my current or future housing circumstance. You are responsible for your own housing, we will do our best to help, but cannot guarantee any results.

Captcha *

Name