Sep /14
PRE-ASSESSMENT FORM
Completion of this form does NOT guarantee loan approval
Application Date:__________________________
How did you hear about the Sources Rent Bank? __________________________________________
Last Name: ______________________________ First Name:_____________________________
Present Address: ________________________________________________________________
Phone:_______________ Cell: ________________ E-mail:________________________________
Male
Female
Date of Birth (MM/DD/YY): _______________________
Current Housing Emergency – Please check all that apply
Received Eviction Notice
Already Evicted / Currently Homeless
Cannot make NEXT month’s rent
BEHIND in rent payments
Received Verbal Eviction Warning
Received Utilities Disconnection Notice
Utilities are already disconnected
Behind in Utilities
Need Damage Deposit
Need 1st month’s rent
What is the cause of your current crisis?
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
What assistance to solve your current housing crisis have you sought? ________________________
________________________________________________________________________________
________________________________________________________________________________
What are possible solutions to your housing crisis? ________________________________________
_________________________________________________________________________________
Additional Information/Comments: _____________________________________________________
_________________________________________________________________________________
Sep /14
QUESTIONS:
1. If behind on rent, how much do you owe (i.e. rental arrears)? ______________
2. If you need NEXT month’s rent how much do you need? ____________
3. If behind with utility payments, how much do you owe to Hydro? _____________
4. If behind with utility payments, how much do you owe to Fortis BC? __________
5. What is the total assistance you require? _______________
6. Is this application for: Individual
or Family
8.
How many dependents do you have (i.e. non-income earners)? ______________
9.
How many income earners beside yourself live in your household? ____________
10. How long have you lived at your current address? _________________________
11. How long did you live at your previous address? __________________________
12. Are you a Canadian Citizen?
Yes
No
13. Do you have a bank account?
Yes
No
14. Can you provide 3 months of bank statements?
Yes
No
15. Do you have 2 pieces of government issued ID (One Photo?)
16. Are you 19 years of age or older?
Yes
Yes
No
No
17. Are you planning to move in the near future?
Yes
No
18. Do you have any Credit Cards, Pay Day Loans or other Loans?
Yes
No
If yes, what is the total amount of your credit card / loan debt? ____________________
19. Have you recently declared bankruptcy?
Yes
20. If yes, has your bankruptcy been discharged?
21. Do you have any personal references?
No
Yes
Yes
No
No
22. What are your current sources of income?___________________________________
23. What is your total monthly income? _________________________________________
24. What is the total monthly income for your household? __________________________
25. What is your current monthly rent? _________________________________________
26. What are your total monthly expenses? (including rent)________________________
27. How much household debt do you have? __________________________
28. Have you been free of substance addictions for 1 year?
Yes
No
Not Applicable
Please send completed form by email, fax, mail or drop in person to: Sources RENT BANK
Newton Resource Centre
#102-13771 72A Ave., Surrey BC V3W 9C6
Email: [email protected]
Phone: 604-547-0123
Fax: 604-596-2319