951 Beesley Rd. Manson's Landing, BC

All information provided on this form will be kept in strict confidence by the CHS Tenanting Committee.

Applicants must be at least 55 years old.
Applicants must currently reside on Cortes Island.
Applicants must be capable of independent living.
Priority given to applicants in financial need.
Rent is $900/month with BC Housing subsidies available for units 7-10.

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1. Application Date

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2. Name

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3. Address

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4. Telephone Number

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6. Date of Birth:

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7. Citizenship

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8. Duration of full-time residency on Cortes Island:

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9. If part-time, how many months per year and for how many years?

Size of Unit Preferred: There are three types of rental units as follows:
a) four units approx 750 sq. ft. (one-bedroom)
b) two units approx 560 sq. ft. (one-bedroom)
c) four units Rent-Geared to Income (RGI) approx. 650 sq. ft. (one-bedroom)

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10. If you were able to choose, which of these would you prefer: (rank order, if you like)
a) b) c)

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11. Please describe your current housing situation on Cortes Island:

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12. Residency history:
Please list your addresses for the past three years, including the name(s) of your landlord(s) and phone number(s).

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13. Annual net income:
(T4 working income, self-employment income, pensions, rental property income, interest or mortgage/loan income, RIF income, annuities etc.). Note that you will be required to submit your federal income tax returns and further detailed information for the past two years if you would like to qualify for a subsidized Rent-Geared-to-Income (RGI) unit.

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14. Please identify any medical conditions or major disabilities:

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15. Do you have any household pets at present?

Please note that there will be certain limitations set on pet ownership, while in residence.

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16. Do you smoke?

Applicants should note that CHS has a zero-tolerance policy on smoking inside the residential units and on the property.
The aim of the CHS is to provide accommodation for independent living. It does not provide services such as housekeeping, cooking or personal care.

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17. Are you able to do light housekeeping?

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18. Are you able to do your own cooking?

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19. Do you require assistance with personal care?

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20. Please describe any other considerations, situations, or special circumstances that you feel may positively influence your application, such as community work, board membership or working for voluntary organizations, etc.

Successful applicants will be required to sign a one-year lease, which will be renewed if all
conditions of occupancy continue to be met. As a unit becomes available, the Tenanting Committee will assess all applications on file. If an applicant is offered a unit, but is not able to accept it at that time, then the committee will offer the unit to the next qualified applicant.

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21. I declare that all the information in this application is correct and complete.

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22. I authorize the CHS to make any inquiries that are deemed necessary to verify the information given in this application; and pursuant to the Freedom of Information Act any person, corporation or social agency to release to the CHS any information pertinent to the assessment of this application; and the CHS to receive and exchange credit bureau information and my previous landlord's credit and other information about me to be used in the decision-making process determining eligibility for occupation of a Seniors Village rental unit.

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