New Sakura-So Application

Applicant

The following section contains questions about the applicant

First Name:*

Last Name:*

Home Phone Number:*

Alternative Phone Number:

Email:*

Occupation:*

Employer Name:*

Employer Address:*

What is your primary language?*

English
Japanese

If other, enter language name here:

What is your status in Canada?*

Citizen
Permanent Resident
Refugee Claimant
Sponsored Immigrant

If you are a permanent resident, please specify the date you became a Permanent Resident

Name of an alternate contact:*

Alternate Contact Phone number:*

Email:*

Co-Applicant

The following section contains questions about the co-applicant

First Name:*

Last Name:*

Phone Number:*

Email:*

What is your relationship to the applicant?*

Health

The following section contains questions about the applicant's health

Do you need a wheelchair accessible apartment?*

Yes
No

Do you receive home support services?*

Yes
No

If you receive home support services, how many day a week does your home support worker come?

Current Housing

The following section contains questions about your current housing situation

What is your current address:*

How long have you lived at your current address:*

Name of current Landlord or Building Manager:*

Do you give permission for us to contact your landlord?*

Yes
No

Did your landlord give you a Notice to end Residential Tenancy?*

Yes
No

If yes, explain why you received the notice

Are you presently living in subsidized housing?*

Yes
No

Are you living with family/friends?*

Yes
No

Describe your current housing*

Do you?*
Rent
Share Expenses
Own
Have free accommodation

Does your rent include?*
Heat: Yes No
Electricity: Yes No

How much is your current monthly rent?*

How much is your average monthly hydro and heat?*

Do you own a vehicle?*
Yes
No

Other comments about your present housing and neighborhood

Do you have easy access to transportation and shopping

Please describe your interests

Please list two people and their phone numbers for references*

Household Income - Applicant

The following section contains questions about your sources of income

How much monthly income do you receive from the following sources*

Employment Income: $

GIS Guaranteed Income Supplement: $

OAS Old Age Security Pension: $

DVA Disabled Veterans Allowance: $

CPP Canada Pension Plan: $

Employment Insurance: $

Disability Benefits: $

Other (please specify):

Total Gross Monthly Income: $

Household Income - Co-Applicant

The following section contains questions about your Co-Applicant's Source of Income

How much monthly income do you receive from the following sources*

Employment Income: $

GIS Guaranteed Income Supplement: $

OAS Old Age Security Pension: $

DVA Disabled Veterans Allowance: $

CPP Canada Pension Plan: $

Employment Insurance: $

Disability Benefits: $

Other (please specify):

Total Gross Monthly Income: $

Assets

The following section contains questions about your Applicant's Assets

List the value of all the assets held by you and your co-applicant in the following categories*

Stocks/Bonds/Term Deposits: $

Bank balances/Cash: $

Real Estate Owned: $

For other assets do not include personal belongings like car, furniture, or jewelry. Also, do not include assets that have the potential to ear now or in the future, such as equity pension plan RRSPS.

Other Assets (describe)

Total Value of all assets: $