Apply For Independent Living

Number of Bedrooms *

One
Two
Three

Applicant First Name *

Applicant Last Name *

Applicant Courtesy *

Applicant Birth Date: *

Co-applicant First Name

Co-applicant Last Name

Co-applicant Courtesy

Co-applicant Birth Date

Mailing Address *

City

Province

Postal Code:

Phone (H) *

Phone (C)

Phone (W)

Email *

Your present form of accommodation is: *

Renting
Non-Profit Housing
Homeowner
Living with Family
Other

Other *

Do you require parking? *

Do you require an accessibility suite? *

Riverside Lions strives to remain free of bed bugs. Applicants who have been exposed to bed bugs will be required to follow certain procedures prior to moving in to Riverside Lions.

Have you ever been exposed to bed bugs? *

Riverside Lions does not permit smoking within our buildings. Will you and your visitors comply with our non-smoking policy? *

Income Source

Statement of Income

Monthly Salary or Wages/Hr

APPLICANT

Monthly Salary or Wages/Hr

CO-APPLICANT

Old Age Security/Month

APPLICANT

Old Age Security/Month

CO-APPLICANT

Guaranteed Income Supplement/Month

APPLICANT

Guaranteed Income Supplement/Month

CO-APPLICANT

Spouse’s Allowance/Month

APPLICANT

Spouse’s Allowance/Month

CO-APPLICANT

Canada Pension/Month

APPLICANT

Canada Pension/Month

CO-APPLICANT

Unemployment Insurance/Month

APPLICANT

Unemployment Insurance/Month

CO-APPLICANT

War Veteran’s Allowances and Civilian War Allowances/Month

APPLICANT

War Veteran’s Allowances and Civilian War Allowances/Month

CO-APPLICANT

Manitoba Supplement (55+)/Month

APPLICANT

Manitoba Supplement (55+)/Month

CO-APPLICANT

Social Allowances/Month

APPLICANT

Social Allowances/Month

CO-APPLICANT

Private Pensions/Month

APPLICANT

Private Pensions/Month

CO-APPLICANT

Private Pensions/Month (Please Specify)

APPLICANT

Private Pensions/Month (Please Specify)

CO-APPLICANT

Disability Pension/Month

APPLICANT

Disability Pension/Month

CO-APPLICANT

Pension from Other Countries/Month

APPLICANT

Pension from Other Countries/Month

CO-APPLICANT

Income from Investments (Stocks, Bonds, Savings, Certificates)/Month

APPLICANT

Income from Investments (Stocks, Bonds, Savings, Certificates)/Month

CO-APPLICANT

Rents, Annuities, Interest Income/Month

APPLICANT

Rents, Annuities, Interest Income/Month

CO-APPLICANT

Other Monthly Income

APPLICANT

Other Monthly Income

CO-APPLICANT

Please Specify

APPLICANT

Please Specify

CO-APPLICANT

Alternate Contact Information

If you wish, you may provide an alternative contact in the event your information changes and we are unable to reach you. Please include the contact information below.

Contact 1

Name

Relationship to applicant

Phone (C)

Phone (H)

Phone (W)

Phone (E)

Special Instructions or Comments

Contact 2

Name

Relationship to applicant

Phone (C)

Phone (H)

Phone (W)

Phone (E)

Special Instructions or Comments

I/We declare the above information to be correct:

Dated *

Applicant’s Signature *

Dated

Co-applicant’s Signature

All information you provide to us shall be kept private and will be used for the sole purpose of assessing and processing your application for residency and for no other purpose.

Medical Information is Voluntary

Do you have any health problems that Riverside Lions Estates should be aware of?

Do you receive Homecare services?

Independent Living Application for Residency

Income Source

Statement of Income

Alternate Contact Information

Contact 1

Contact 2

Medical Information is Voluntary

Independent Living
Application for Residency