Application Form

Submit completed The Shelter Aid for Elderly Renters (SAFER) program helps make
application with rents more affordable for BC seniors with low to moderate incomes.
supporting documents to: SAFER provides monthly cash payments to eligible BC residents who
are age 60 or over and who pay rent for their homes.
Shelter Aid for Elderly Renters
101 – 4555 Kingsway
Who is eligible?
Burnaby, BC V5H 4V8
You may be eligible for SAFER if you meet all of the following
conditions:
1. You are age 60 or older.
2. You or your spouse (if applicable) have lived in British Columbia
PLEASE: for the full 12 months immediately preceding your application.
Print clearly. 3. You and your spouse (if applicable) are one of the following:
Do NOT include original Canadian citizen(s); or authorized to take up permanent
documents (we require residence in Canada; or Convention refugee(s).
photocopies only). 4. You pay more than 30% of your gross (before tax) monthly
Do NOT use staples. household income towards the rent for your home (or for the cost
of pad rental for a manufactured home (trailer) that you own and
occupy).
5. Your gross (before tax) monthly household income does not
exceed the maximum allowable income. Maximum income
varies based on household size and location in the province.
Avoid Processing Delays:
6. You do not receive income assistance through the B.C.
Eligibility cannot be determined
Employment and Assistance Act or the Employment and
until you provide all required
Assistance for Persons with Disabilities Act (excluding Medical
documentation.
Services only).
The most common cause of
processing delays is missing
documents. For more information on eligibility, please see the SAFER brochure
Applications must: (online at www.bchousing.org) or call the SAFER office at
604-433-2218 (or toll-free at 1-800-257-7756).
• Be complete, signed, and
dated
Benefit Effective Date:
• Include proof of income,
age and rent The Benefit is effective the latter of:
• Include bank information for  The first day of the month in which your application is received by
Direct Deposit our office; or
Applications submitted without  The first day of the month in which you are deemed eligible for
required supporting documents SAFER.
can be held for a maximum of
90 days. The Benefit is a non-taxable reimbursement for rent already paid, and
is paid at the end of each month.

For help with this form, please contact the SAFER office at 604-433-2218 or 1-800-257-7756 HOU-035 (2019-05-08)
Page 1
 FOR OFFICE USE ONLY
PLEASE
PRINT Date: Status: File:
CLEARLY
1. Applicant Information
Social Insurance Number Last Name First Name(s)

Birth Date (dd/mm/yyyy) Age Sex (M/F) Born in Canada? (Yes/No)

2. Spouse or Partner Information (if applicable)

Social Insurance Number Last name First name(s)

Birth Date (dd/mm/yyyy) Age Sex (M/F) Born in Canada? (Yes/No)

3. Consent For Release of Information From Canada Revenue Agency

To determine eligibility for the Shelter Aid For Elderly Renters Program, income tax information is required. You may
give the Canada Revenue Agency permission to provide the required information or you may provide the tax information
directly to BC Housing yourself.
SELECT Option 1 or Option 2 below. Do not check more than one box.

Option 1: Consent Granted Option 2: Consent Not Granted

I/We hereby consent to the release, by the Canada I/We do not give consent for the Canada Revenue
Revenue Agency, to BC Housing of information from Agency to provide my/our income tax information to
my/our income tax records, whether supplied by me/us or BC Housing. I/We understand that I/we will be responsible
by a third party. The information will be relevant to, and for providing verification of my/our income and assets in
used solely for the purpose of, determining and verifying order to confirm eligibility for rental assistance/benefit.
my/our eligibility, entitlement for and the general I/We have attached the following proof:
administration and enforcement of rental
assistance/subsidies from BC Housing. o Copy of Notice of Assessment for the last filed
tax year.
This authorization is valid for the current taxation year, o Copy of detailed Income Tax Return for the
the two taxation years immediately preceding the current last filed tax year.
taxation year and each subsequent consecutive taxation o If self-employed: Copy of Statement of Business
year for which I/we have applied for rental Activities and all related worksheets (only
assistance/benefit. required for individuals with self-employment
I/we understand that if I/we wish to withdraw this income, either business or professional on their
consent, I/we may do so at any time by writing to: tax return).

Manager, Applicant Services If you are not able to locate your income documents,
BC Housing, 1701 - 4555 Kingsway please obtain a Proof of Income Statement (Option C
Burnaby, BC V5H 4V8. print) from www.cra.gc.ca/myaccount or contact the
Canada Revenue Agency at 1-800 959-8281.

Applicant:

Print Name Signature Date

Spouse:

Print Name Signature Date

For help with this form, please contact the SAFER office at 604-433-2218 or 1-800-257-7756 HOU-035 (2019-05-08)
Page 2
 4. Residency Information
4a. Have you lived in B.C. for the past twelve months?  Yes  No

If no, when did you move to B.C.?

How long have you lived in Canada?

4b. Please list your address(es) for the last 12 months:

From Date To Date
Address(es) Landlord Name Landlord Phone #
(dd/mm/yyyy) (dd/mm/yyyy)

Current address

4c. If you or your spouse were not born in Canada, please complete the following:
Date moved Sponsored Immigrants Only
Current status in
Name to Canada End Date of
Canada Name of Sponsor
(dd/mm/yyyy) Sponsorship Agreement

5. Household Information - Check all options that apply

 Living Alone  Living with a spouse or common-law partner

 Sharing with another adult(s)  Other, describe:

5a. List all other persons who are living with you. (if required attach additional names on a separate sheet)
Relationship
Birth Date* Sex*
Last Name Given Names to Age
(dd/mm/yyyy) (M/F)
Applicant

*Birth Date and Sex not required for children aged 25 or older or any other adult(s) living in the household.

5b. (Optional) Do you or anyone in your household identify as being an Indigenous person of Canada?

 Yes  No If yes, please select the option(s) that best describes your Indigenous identity:
 First Nations  Métis  Inuit  Other

For help with this form, please contact the SAFER office at 604-433-2218 or 1-800-257-7756 HOU-035 (2019-05-08)
Page 3
 6. Contact Information
Home Phone # Work Phone #
( )- ( )-
Cell Phone # Email
( )-
Optional: Name of person we can leave messages with Message person phone number
( )-
Optional: Authorized Contact* name and relationship to you Authorized Contact phone number
( )-
If Applicable: Power of Attorney name Power of Attorney phone number
( )-
*By providing an authorized contact, you are giving permission for BC Housing to exchange information with that authorized contact
in order to maintain and update your SAFER file. To remove an authorized contact, please contact BC Housing.

7. Residential Address
Apt # Street # Street Name

City Postal Code

B.C.

7a. Mailing Address *Mail is sent to the residential address, with the exception of rural areas with no mail delivery.
Apt # Street # Street Name

City Postal Code

B.C.

7b. Landlord Information

Landlord Name Landlord Phone

Landlord Address

8. Rent Information
8a. Do you:  Rent  Own  Life Lease  Rent-to-own
How much is your rent? $______________ (Do not include hydro, cable or parking in rent amount)
Is this:  Monthly  Weekly  Nightly/Daily

Does your rent include heat?  Yes  No

Is your rent subsidized?  Yes  No

Does your rent include meals?  Yes  No If Yes, how many meals per day? __________

Do you share a kitchen or bathroom with another tenant or your landlord?  Yes  No

8b. Check all of the following that apply:

 I live in a self-contained unit (apartment,  I live with family or friends (other than spouse/common
house, townhouse) law partner)
 I live in a self-contained basement suite  I live in a Housing Co-operative
 I live in a Manufactured/Trailer/Mobile home  I live in a Hotel/Motel

 Other (describe)

If you live in a manufactured/trailer/mobile home, do you?  Own  Rent Trailer Rent $ ____________

Do you pay pad rental?  Yes  No Pad Rent $ ____________

For help with this form, please contact the SAFER office at 604-433-2218 or 1-800-257-7756 HOU-035 (2019-05-08)
Page 4
 9. Income Information
9a. Have any income sources reported on your tax return stopped or permanently decreased?  Yes  No
If yes, please describe:

9b. Did you stop working in the last 24 months?  Yes  No

If yes, when did you last work? (Month/Year)

9c. Do you plan to seek employment in the next year?  Yes  No

9d. Have you (or your spouse) received income assistance from the Ministry of Social Development and
Poverty Reduction in the past 24 months?  Yes  No
If yes, when was the last payment received? (Month/Year)

9e. Did you (or your spouse) receive a T5007 Income Tax slip from the BC Bus Pass Program last year?
 Yes  No
If yes, include a copy of the T-slip and this amount will be excluded from your income.

9f. Did you receive any income in the last year that does not appear on your tax return (family support, on-
reserve employment, foreign pensions, etc.)?  Yes  No
If yes, please describe and attach supporting documentation:

9g. Do you have any income from self-employment?  Yes  No

If yes, please attach a Statement of Income and Expenses from last year’s Income Tax return and all related
worksheets (T2125)

9h. Current Monthly Income (for both applicant and spouse, if applicable)
List all current Income Sources including any regular ongoing funds received from non-taxable Sources:
(Employment, Employment Insurance, Pensions both Foreign and Domestic, Support Income, On-Reserve APPLICANT SPOUSE
Employment, Seasonal Employment, Family Support, and all other sources)

Old Age Security, Guaranteed Income Supplement, and Allowance for the Survivor (if applicable) $ $
$ $
$ $
$ $
$ $
$ $
 Note: See attached checklist for details of acceptable proof of income.

NOTE:
Proof of income must be provided before this application can be processed. Please attach:
 Income Tax Information, either consent for release of tax information from Canada Revenue Agency (CRA);
or Copies of last year’s Income Tax Notice of Assessment AND detailed Income Tax return; and
 If self-employed, statement of Income and Expenses from last year’s Income Tax return and related
worksheets (form T2125); and
 If you declared bankruptcy in the last two years, both the pre- and post-bankruptcy returns; and
 If any income reported on your tax return have stopped or permanently decreased, proof of current income
from all sources; and
 Proof of any non-taxable income.

For help with this form, please contact the SAFER office at 604-433-2218 or 1-800-257-7756 HOU-035 (2019-05-08)
Page 5
 Purpose of this form:
This form collects specific information from applicants (the person(s) filling out the form) to determine
eligibility for assistance through the Shelter Aid for Elderly Renters (SAFER) program. The information is
collected in accordance with section 26(c) of the Freedom of Information and Protection of Privacy Act.
If you have any questions about the collection of your information, please call 604-433-1711 and ask to
speak to BC Housing’s Privacy Officer or write to 4555 Kingsway, Burnaby, BC, V5H 4V8.

10. Declaration and Consent PLEASE READ AND SIGN

I/We declare:
 This is my/our application and all the information in it is true, correct and complete in every respect;
fully discloses my/our income from all sources; and accurately represents my current living
circumstances.
I/We permit:
 BC Housing to verify any of the information I/we have provided in this application in order to access
my/our eligibility for benefits under the Shelter Aid For Elderly Renters Program.
I/We acknowledge and understand that:
 It is my/our responsibility to promptly provide, or cause to be provided, all information and
documentation that is reasonably requested by BC Housing to determine my/our eligibility for benefits
and/or for audit purposes. I/we are responsible to immediately inform BC Housing of any changes in
my/our address, rent, marital status, family size, or the people sharing my/our accommodation so that
my/our benefit can be adjusted accordingly.
 Failure to report changes in my/our address or household composition may result in an interruption or
suspension of benefits and may also result in an overpayment, which I/we will be required to repay.
 Failure to report if I/we begin to receive income assistance through the Ministry responsible for the
B.C. Employment and Assistance Act or the Employment and Assistance for Persons with Disabilities
Act will result in an overpayment of benefits which I/we will be required to repay.
 Benefits paid under this agreement is a reimbursement of actual rent paid and if I/we fail to pay the
full rental amount BC Housing may immediately stop payment of benefits and I/we agree to return to
BC Housing all benefits paid for periods in which the full rental amount was not paid.
 BC Housing will audit some Shelter Aid For Elderly Renters Program applications and benefits may be
adjusted if the audit reveals errors or omissions in any information.
 Misrepresentation of the information provided, in writing or by omission, may result in recovery of
benefits in addition to any other remedies available in law or equity.
 If I/we wish to withdraw this Declaration and Consent, I/we may do so at any time in writing to
BC Housing; however, withdrawal will result in my/our being ineligible for assistance through the
Shelter Aid For Elderly Renters Program.
Signature of Applicant Date Signature of Spouse (if applicable) Date

Next Steps
1. Sign & Date Application.
2. Attach Supporting Documents: (Do not send original documents)
Review the attached checklist for more information on supporting documents.
3. Submit Application:
Shelter Aid for Elderly Renters, 101 – 4555 Kingsway, Burnaby, BC V5H 4V8
NOTE: The most common cause of processing delays is missing documentation. Applications submitted
without all required supporting documents can be held for a maximum of 90 days.

For help with this form, please contact the SAFER office at 604-433-2218 or 1-800-257-7756 HOU-035 (2019-05-08)
Page 6
SAFER Direct Deposit
Assistance is paid by direct deposit to your account on the last working day of each month. The
account must be in the name of the applicant and/or spouse (if applicable). The information
requested will provide BC Housing with the required financial institution, transit and account numbers
needed for processing automatic payments to your account.
Please provide one of the following:
 A printed, personalized blank cheque marked VOID; or
 A Preauthorized Debit Form provided by your financial institution; or
 Have your financial institution complete the information below:

Name of Applicant

Have the following completed by your financial institution if you are not attaching a void cheque or a
Preauthorized Debit form.
Transit Number Bank Number Account Number

Name(s) on the account Phone number of financial institution

Financial Institution Stamp:

Proof of Rent - Landlord Declaration

Not required if a Tenancy Agreement or Rent Receipt has been provided with application form.

I __________________________________confirm that I am renting _____________________________________ BC

Landlord / Building Manager Name (Print) Rental address (Unit #, Street #, City)

To ___________________________________________________ since _________________________

Print Tenant’s Name(s) Date tenancy started (MM/DD/YY)

The Rent is $______________ per  Month  Week  Night

Heat included?  Yes  No

Landlord Signature Landlord Phone # Date:

Please return to:

SAFER Department
BC Housing
#101 – 4555 Kingsway, Burnaby, BC V5H 4V8

HOU-035 (2019-05-08)
Shelter Aid for Elderly Renters (SAFER) - Application Checklist

Incomplete applications will experience processing delays. Before submitting your application form please
review the following to make sure that all required information is included.
 Applications are effective the latter of the month in which they are received by the Shelter Aid for Elderly
Renters program or the month in which an applicant is deemed eligible.
 Incomplete applications will experience processing delays and can be held for up to 90 days to allow time to
gather and submit missing documentation.
 After 90 days, incomplete applications will be cancelled and the applicant will be required to complete a new
application. The effective date will be adjusted to the month in which the new application is received.

Do NOT include original documents (we require photocopies only)

Identification and Residency (Required for applicant and spouse, if applicable)
If you are receiving Old Age Security, attach a copy of one of the following:
 Birth or baptismal certificate, Passport, Driver’s License or a BC ID Card.
If you are not in receipt of Old Age Security, please attach:
 If born in Canada, Copy of Canadian birth or baptismal certificate, or Passport.
 If not born in Canada, documentation showing date of birth as well as your status in Canada and that you are
not under private sponsorship. For more information, please call 604-433-2218 or toll-free at 1-800-257-7756.
Power of Attorney (If applicable)
 Attach Power of Attorney authorizing documents.
Direct Deposit
 Attach a personalized blank cheque marked VOID to the application form; or
 Attach a Preauthorized Debit Form provided by your financial institution; or
 Have your financial institution complete the SAFER Direct Deposit section of this application.
Proof of Rent
 Rent Receipt showing address, rent amount, date and landlord name; or
 Copy of recent Rent Increase Notice; or
 Copy of Lease or Tenancy Agreement (if signed within the past 12 months); or
 Have your landlord complete the Proof of Rent - Landlord Declaration section of this application.
Income Tax Information (Required for applicant and spouse, if applicable)
 Provide consent for release of tax information from Canada Revenue Agency (CRA) on page 2 of this
application; or
 Provide copies of last year’s Income Tax Notice of Assessment AND detailed Income Tax return (include all
pages); or T-slips from all income sources.
Note: If bankruptcy was declared within the last two taxation years, provide copies of the Income Tax Notices of
Assessment and detailed Income Tax returns for both the pre- and post-bankruptcy.
Proof of Self-Employment (If applicable)
If last year’s annual income included income from self-employment, attach:
 Statement of Income and Expenses from last year’s Income Tax return and all related worksheets (form
T2125).
Proof of Current Income (If applicable)
If any income reported on your tax return have stopped or permanently decreased, attach:
 Proof of CURRENT gross monthly income, from all sources (cheque stubs, letter from employer bank
statements showing direct deposits or other income statement).
BC Bus Pass T5007 Tax Slip (If applicable)
If you (or your spouse, if applicable) received a T5 slip from the BC Bus Pass Program last year, attach:
 The T5007 tax slip that indicates the bus pass benefit amount.

For assistance call 604-433-2218 or toll-free at 1-800-257-7756 from outside the Lower Mainland.

HOU-035 (2019-05-08)