Surrey, White Rock, Delta, Township and City of Langley Rent Bank Form Please enable JavaScript in your browser to complete this form. - Step 1 of 3PART ONE: YOUR INFORMATIONApplicant TypeIndividualFamilyDo you have two pieces of ID?YesNoYou must have at least one piece of Photo IDNAME AND CONTACT INFORMATIONFirst Name *Last Name *Phone *CellEmail *Preferred Method of CommunicationPhoneEmailEitherYOUR ADDRESSAddress *City *Province *Postal CodeAdults in the HouseholdNumber of Adults in the Household over the age of 18 years oldChildren/DependentsNumber of Children/Dependents in the HouseholdTotal People in the HouseholdTotal Number of People in the HouseholdPERSONAL INFORMATIONDate of Birth *MM123456789101112/DD12345678910111213141516171819202122232425262728293031/YYYY202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Legal StatusCanadian CitizenLanded ImmigrantPermanent ResidentConvention RefugeeFirst NationsOtherPlease describe.ie. International Student, Temporary Foreign WorkerMarital StatusSingleCommon LawMarriedDivorcedWidowedOtherNextPART TWO: INCOME AND FINANCESINCOMECheckboxes (check all that apply) *Employed Full-TimeEmployed Part-TimeSelf-EmployedCERB BenefitWorker's Compensation Benefits (WCB)Employment Insurance (EI)Child Tax BenefitsTax CreditsIncome Assistance (IA)Persons with Disability (PWD)Persons w/ Persistent Multiple Barriers (PPMB)Pension(s)/ CPP / Old Age Security (OAS)Child Support/ AlimonyCPP Disability PensionPrivate/Work Disability PensionPrivate/Work Retirement PensionYour Total Monthly Income After TaxesPlease round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)Number of Income Earners in Your HouseholdTotal Household Monthly Income After TaxesPlease round up to the nearest dollar and use whole numbers with no commas or decimals permitted (ie. 1200)FINANCESPlease check all that applyI have a bank accountI can provide 3 months of bank statementsDebts: I have credit card debtDebts: I have payday loan debtDebts: I have other loansDebts: I have outstanding debt to a Rent BankI have recently declared bankruptcyWhat 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.NextTELL US MORE ABOUT YOUR CURRENT SITUATIONWhat is Your Current Housing Emergency? (Check All that Apply) *Written Eviction NoticeAlready Evicted/Currently HomelessCannot make next month’s rentBehind in RentReceived Verbal Eviction WarningReceived Utilities Disconnection NoticeUtilities already disconnectedBehind in UtilitiesNeed Damage DepositNeed 1st month’s rentPet DepositPlease describe your current crisis or the reason for your application.Max 150 wordsWhat other sources of financial assistance have you sought? (Check All that Apply)EICERBWCBSocial AssistanceCPPFamilyFriendsOtherPlease Describe.What was the Result?Applied, and ApprovedApplied, but WaitingDeclinedAccessing Other SourcesNot Tried Other SourcesDETERMINING YOUR REQUESTHow 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 APPLICATIONTerms of Service *I have read and agree to the Terms of Service Listed BelowPromise 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 * = EmailSubmit My Application