List all household members, excluding yourself.

• Relationship to applicant *

  Remove this person

  First Name *

  Last Name *

  Birth Date * (MM/DD/YYYY)

  Gender *

  Does this person live with the applicant full time right now?

  Yes No

  If No: Please provide the name of the person and the number of days per week they live with you.

  Days per week

  Shared custody? Yes No

  If not shared custody, why does the person not live with you full-time?

  Housing history

  Has this adult lived with you for less than two years?

  Yes No

  If yes, please list their last three landlords' information:

  Rental Address (street and city)	From (MM/DD/YYYY)	To (MM/DD/YYYY)	Name of Landlord	Landlord's Phone #	Reason for leaving

  Income

  Income: Tenants, dependents and other occupants must provide proof of income. Please check off which of the following apply to you. Please ensure you have the applicable documentation available to provide at a future date.

  NOTICE OF ASSESSMENT FOR CURRENT YEAR from Canada Customs and Revenue Agency (CCRA) for all occupants 19 years and older (if you do not have this document, contact CCRA at 1-800-959-8281

  AND

  EMPLOYED, provide copies of three current consecutive pay stubs which show gross income and deductions

  Employment Reference

  Company Name

  Contact

  Phone Number

  Start Date

  SELF-EMPLOYED, provide copy of Statement of Business Activities and Income Tax Return

  OTHER INCOME (e.g. EI, pensions, Ministry benefits)

  please explain:

  Income Source:

  Income Source * (job, EI, pensions, etc.)

  Gross Monthly Income *

  $

  Asset Summary:

  Do your Total Assets exceed $100,000?

  Yes No

  Funds held in a financial institution, including banks, trust companies, etc.

  $

  Stocks, bonds, and exchange-traded funds.

  $

  Cash and other items of a potential income earning nature.

  $

  Equity in real property.

  $

  Equity in a business, including cash, GICs, bonds, stocks, equity in real estate, or equity in any other tangible asset.

  $

  Items of personal property value over $10,000.

  $

  Total

  $

  Health & Mobility

  Does this dependent have problems with stairs?

  No problem with stairs Cannot deal with stairs Can only deal with (#) stairs

  Does this person use a wheelchair?

  Yes No

  Does this person use a scooter?

  Yes No

  If Yes: Does this person use the wheelchair or scooter in the home?

  Yes No

  Does this person have any other health conditions or disabilities?

  Yes No

  NOTE: MVHC may require you to provide additional documentation, such as a doctor's note, about the health condition or disability and how it affects your housing needs.

  If Yes: Explain the health condition or disability and how it affects your housing needs. Describe any special requirements your household needs because of mobility or health conditions.