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PALMER PLACE APPLICATION FORM

Please Fill Out Application Form Below

"*" indicates required fields

MM slash DD slash YYYY

Accommodation required and Preferences

Number of bedrooms required*
Do you require a wheelchair accessible suite?*
Do you require parking?*

Household Information

Please list yourself on the first line and then all those who will live with you.
*
Full Name
Date of Birth (YYYY/MM/DD)
Pronouns (She/He/They)
Relationship to Applicant
 

Residency History

Please list your addresses for the past 4 years.
*
Address
From (YYYY/MM/DD)
To (YYYY/MM/DD)
Landlords Name and Number
 

Current Accomodation

Are you currently renting?*
What kind of rental is it?*

Income Eligibility Brackets

Annual gross household income required to be eligible in many affordable housing programs. 2023 level grid:

Campbell River

Unit type

Income must be under
1 Bedroom / Studio $41,500
2 Bedroom $49,500

Courtenay/Comox Valley

Unit type

Income must be under
1 Bedroom / Studio $44,000
2 Bedroom $55,500
To comply with BC Housing’s standard of HIL (Housing Income Limits) and prioritizing those with limited income; the chart above will state the eligibility of specific units for applicants based on yearly income.

Income Information

Required to establish Low & Moderate Income Limit eligibility. Proof of income must be provided for the Applicant(s) as well as all adult household members identified in this Application (anyone age 19 older). Please attach the following:
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        Please provide employment reference*
        Company Name
        Employer Name and Number
        Start Date
         
        If other income (example: EI, pensions, Ministry benefits), please explain*
        Name (first, Last)
        Income Source (Job, EI, PWD, Pension, etc.)
        Monthly Income
         
        Applicant Checklist

        Check the box(s) that best reflect your current circumstances

        Are you at risk of violence or abuse?*
        Are you currently staying at Transition Housing?*
        Have you experienced any form of violence or abuse?*
        Are you at risk of homelessness?*
        Are you an adult with a diverse ability?*
        Do you currently receive support from CLBC?*
        Are you currently working with any mental health teams?*
        Do you currently access support services at Rose / Eagle Harbour?*
        Are you currently receiving drug and alcohol treatment?*
        Are you a smoker?*
        Do you have Pets?*
        Do you have Children?*
        Are you expecting any changes to your household composition in the next year?*

        Acknowledgement

        I/We certify that the information on this form is true, correct, and complete in every respect to the best of my/our knowledge and can be verified by Rivercity Inclusion including obtaining credit and/or personal reports on me/us from one or more agencies or individuals. I/We hereby authorize agencies or individuals, such as CRNITS, to provide information to Rivercity Inclusion Society as it is relative to assessment of the application. I/We understand this application does not constitute an agreement on the part of Rivercity Inclusion Society to provide me/us with rental housing.
        *

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