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About Us
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Accessibility Feedback Form
Our Services
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Adult Services
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Ironwood Place
Lion’s Place
Palmer Place
Join Our Team
Opportunities
Benefits
Contact
Membership
Ways to Give
Donations
Fundraising
Staff
Home
About Us
Who We Are
Mission Vision Values
Board of Directors
Management Team
Accreditation
Reports
Accessibility Feedback Form
Our Services
Child and Youth Services
Adult Services
Social Enterprises
Housing
Ironwood Place
Lion’s Place
Palmer Place
Join Our Team
Opportunities
Benefits
Contact
Membership
Ways to Give
Donations
Fundraising
Staff
Donations
Menu
Home
About Us
Who We Are
Mission Vision Values
Board of Directors
Management Team
Accreditation
Reports
Accessibility Feedback Form
Our Services
Child and Youth Services
Adult Services
Social Enterprises
Housing
Ironwood Place
Lion’s Place
Palmer Place
Join Our Team
Opportunities
Benefits
Contact
Membership
Ways to Give
Donations
Fundraising
Staff
Donations
Donate
PALMER PLACE APPLICATION FORM
Please Fill Out Application Form Below
"
*
" indicates required fields
First Name
*
Last Name
*
List any other names you may be known by
Date of Birth
*
MM slash DD slash YYYY
Cell Phone
*
Other Phone
Email
Accommodation required and Preferences
Number of bedrooms required
*
1 Bedroom
2 Bedrooms
Do you require a wheelchair accessible suite?
*
Yes
No
Do you require parking?
*
Yes
No
Do you have any special living requirements? If yes, please summarize
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
Add
Remove
Residency History
Please list your addresses for the past 4 years.
*
Address
From (YYYY/MM/DD)
To (YYYY/MM/DD)
Landlords Name and Number
Add
Remove
Current Accomodation
Are you currently renting?
*
Yes
No
If you are renting, how much is your monthly payment? $
How many bedrooms?
What kind of rental is it?
*
House
Apartment
Shared Space, Private Room
Other
If Other, please specify
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:
Notice of Assessment for current year from Canada Customs and Revenue Agency. (CCRA) for all occupants 19 years and older (if you do not have this document, contact CCRA at 1-800-959-8281 to request it)
*
Drop files here or
Select files
Max. file size: 50 MB.
If self-employed, copy of Statement of Business Activities and Income Tax Return Attached
*
Drop files here or
Select files
Max. file size: 50 MB.
If employed, copies of three current consecutive pay stubs which show your gross income and deductions.
*
Drop files here or
Select files
Max. file size: 50 MB.
Please provide employment reference
*
Company Name
Employer Name and Number
Start Date
Add
Remove
If other income (example: EI, pensions, Ministry benefits), please explain
*
Name (first, Last)
Income Source (Job, EI, PWD, Pension, etc.)
Monthly Income
Add
Remove
Total Household income
*
Applicant Checklist
Complete application and sign Consent to Release Personal Information
Attach proof of current and consistent income (pay stub, bank statements, etc.)
Statement of business activities and Income Tax (if applicable)
Copy of government issued ID
How did you hear about Palmer Place?
Check the box(s) that best reflect your current circumstances
Are you at risk of violence or abuse?
*
Yes
No
Are you currently staying at Transition Housing?
*
Yes
No
Have you experienced any form of violence or abuse?
*
Yes
No
Are you at risk of homelessness?
*
Yes
No
Are you an adult with a diverse ability?
*
Yes
No
Do you currently receive support from CLBC?
*
Yes
No
Are you currently working with any mental health teams?
*
Yes
No
If yes, please specify which support you are accessing
Do you currently access support services at Rose / Eagle Harbour?
*
Yes
No
Are you currently receiving drug and alcohol treatment?
*
Yes
No
Are you a smoker?
*
Yes
No
Please describe your current housing circumstances: Briefly describe your reason for applying.
*
Do you have Pets?
*
Yes
No
Do you have Children?
*
Yes
No
Ages of Children
*
Are you expecting any changes to your household composition in the next year?
*
Yes
No
If yes, please explain
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.
*
I/We Agree
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