302, 4719 – 48 Avenue

Red Deer, Alberta T4N 3T1

Phone: (403) 343-2177
Fax: (403) 343-2176
Email: admin@rdha.ab.ca

Application for Community Housing and Rent Supplement Programs

Instructions

Please read the following information carefully before completing the application. Answer all the questions in the
application, if a question does not apply to you print NA (not applicable). Please do not leave any blanks. If you have
any questions, please contact Red Deer Housing Authority as listed above.

1. Please review information on Eligibility Requirements and Point Scoring for the purposes of determining need
for social housing. Priority is decided based on a points system according to the Social Housing Accommodation
Regulation. Households with the greatest number of points are considered in greatest need of housing
accommodation and must be allocated housing accommodation on that basis. If your information changes
at any time, please contact us and let us know – this may impact your point score.

2. You may print the application form and fill it in by hand, or complete it online using an electronic signature.
Once done, please save or scan your completed application form in PDF format and attach it along with
your documents as part of your application and email it to admin@rdha.ab.ca or drop/mail it to our Offices
at, 302, 4719 – 48 Avenue, Red Deer, Alberta T4N 3T1.

3. You will be required to provide the following:

• Documentation to verify all sources of household income. i.e.: pay cheque, benefit cheque, child support,
AISH, Social Assistance, Student Funding etc.
• Verification of your government issued picture ID.
• A Copy of most recent Notice of Assessment (Revenue Canada)
• Copy of Alberta Heath Care Card for each member of the household.
• For Rent Subsidy Applications we also need a copy of your lease (if applicable)
• If not a Canadian Citizen, proof of permanent residency/refugee status.

4. Please ensure that all information and documents submitted in and with the application are true to the best
of your knowledge.

5. If you visit the office or speak with a RDHA representative about your file over the phone, please be ready
to verify your identity. If you would like someone who is not listed on the application to be able to speak
with RDHA on your behalf or about your application, please complete a Consent to Release form.

6. Based on the information you provide, we will assess your eligibility for the program you are applying for.
Once you have been found eligible, we will point score your application.
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.

Program Type

Check all programs to which you would like to apply. If you are unfamiliar with the programs, please read the information sheets
available on our website and in our office.

✔ Community Housing: You may be provided with one of our units in Red Deer, Innisfail
or Sylvan Lake.

• Each applicant must have lived or worked in the area for a least three months.
• Each applicant must have dependent children.
• Each household must have less than $25,000.00 in assets (Not including household furnishings)
• Rent is based on 30% of each tenant’s gross household income (before deductions)
• NO PETS PERMITTED

Rent Supplement Program: You keep your current rental unit and we may
supplement a portion of your rent.

 DIRECT RENT SUPPLEMENT (DRS) (if you check this program, please remember to provide a tenancy
agreement/lease). Shared accommodation and room and board are NOT eligible. Basement suites do not qualify
unless certification of a legal suit status is provided from the City/Town.

 PRIVATE LANDLORD RENT SUPPLEMENT (PLRS)

Personal Information

(Primary Applicant) Last Name First Name Phone # Date of Birth (M/D/Y)
Syed Sajjad Haider 4384935058 01/01/1962
Co-Applicant Last name First Name Phone # Date of Birth (M/D/Y)
Syed Vizra 4384935058 03/24/1972
Current Address: City: Postal Code: How long at this address?
72 Montee Sagala Ile Perrot J7v3b7 7 years
Mailing Address if Different than City: Postal Code: Language Preferred
above:
English ☐
✔ French ☐ Other ☐

Are you a legal resident of Canada? Ethnicity

Yes ☐ ✔
No ☐ Caucasian☐ Aboriginal ☐ Welovecanada88@hotmail.com
Email:____________________________________
Other ☐✔ ______________

Page 2 of 9
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.

Household Composition

List all persons who will be living with you Relation to Birth date Age Gender (M/F)
should your application be approved Applicant MO/DAY/YEAR
(First Name, Last Name)
Vizra Wife 03/24/1972 53 F
Arva Daughter 08/04/2009 14 F

1. Are you expecting the number of people in your household to:

Increase? ☐ _______________ or Decrease? ☐ ✔ __________________

2. Have you ever received rent supplement or community housing from RDHA? Please provide the date of
your last payment. ______________________________________
N/a

3. Is there a custody agreement in place for any minor children? (please provide a brief summary of the
agreement) _______________________________________________________________

____________________________________________________________________________

4. Which best describes your current residence? 5. Rooms in your present residence:

House Townhouse Shelter/Emergency Unit

# of bedrooms: 2____
Duplex 4/6 Multiplex Hotel

Trailer Apartment ✔ Legal Basement Suite

6. Do you share your accommodation or a portion thereof with any person(s) NOT listed on this application?

✔ If Yes, how many? Adults: _____

Yes____ or No____ Children: _____

Page 3 of 9
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.

7. How much do you pay in rent per month? $__________

750

✔
8. Have you received a rental increase or rent incentive? Yes____ No____
If yes, what is the new rent and when will this change? _______________________________

✔
9. If you do not pay rent, do you contribute financially? Yes____ No____
If yes, provide details____________________________________________________________

10. Which utilities do you pay for (Check all that apply)
Heat Electricity Water/Sewer

11. Do you have to give one (1) months’ notice prior to moving? Yes____ No____
✔
Term of Lease: 7_____________ Lease Expiry Date: ______________________
06/13/2023

12. Have you been given an eviction notice? Yes____ No____

✔
If you have been given a “NOTICE TO VACATE”, please submit a copy of the notice stating the
reason for the eviction.

13. Do you have a pet(s)? Yes____ No____

✔
If yes what kind and how many? __________________________________________________

14. Do you require a wheelchair accessible suit? Yes____ No____

✔
15. Does your house meet housing and safety standards? Yes____
✔ No____

Please give examples (mould, no heat)

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

16. Check all that apply to you and your household. Please provide documentation where
appropriate.

____ Home is in the process of foreclosure.

____ Selling a home that I/we own.

____ About to be released from a program or facility and have nowhere to live.

Page 4 of 9
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.

____ Fleeing family or other violence/abuse.

____ Homeless or at risk of homelessness.

____ Living in a group home.

____ In bankruptcy or have filed a consumer proposal

____ Are you a Housing First Graduate? Year Completed ___________

17. Please feel free to describe your present circumstances and any information you would like
RDHA to be aware of.

Assets

List the value of the following assets that are applicable or state N/A if not applicable.
Type of Asset Total Value
Bank Account - Savings $2n/a
Bank Account - Chequing $24.98
Bank Account - Other $N/a
Equity in Real Estate $N/a
Stocks, Bonds, Mutual Funds, etc. $N/a
Other Assets $N/a

Page 5 of 9
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.

Does anyone in your household:

Own/Lease a Yes-Lease Equity: Value: Monthly Payment Year, Make and Model:
vehicle ✔ No
Yes-Own $_______ $______ $_______

Is there a 2nd Yes-Lease Equity: Value: Monthly Payment Year, Make and Model:
vehicle in ✔ No
your Yes-Own $_______ $______ $________
household?

Income

List all current sources of income (monthly gross amounts) for everyone:

Source of Income Received per Month Name(s) of Recipients(s)

(list all members who get this
source of income)
Alberta Seniors Benefit (ASB) /
AISH /
Alberta Child Benefit (ACB) /
Alberta Family Employment Tax Credit
(AFETC) /
Band and/or Treaty Funding /
Canadian Pension Plan (CPP) /
Child Support (including section 7) /
Company/Group Pensions /
Canada Child Benefit (CCB) 500.22$ Vizra
Disability Benefit /
Employment Insurance /
Foreign Country Income /
Government Family Support (i.e. kinship,
foster) /
GST 350$ Sajjad
Income Support/Social Assistance 1278.29$ Sajjad/ Vizra
Old Age Security (OAS)/
Guaranteed Income Supplement (GIS) /
Partner/Spousal Support /

Page 6 of 9
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.
Registered Retirement Income Fund (RIFFs) /
Resettlement Assistance (RAP) /
Self-Employment (Statement of Business
Activities) /
Student Loans/Grants /
Support from Family /
Tips /
Workers Compensation Board (WCB) /
Working Income Tax Benefit (WITB) /
Other Sajjad
Quebec pension 70$

Employment

Note: All information regarding your family’s income must be complete and accurate. Provide details
of current employment held in the last 12 months. (Begin with the most recent employer).

Head of Household: Name___________________________________

Employed By: Dates Employed Hours Rate Earnings Total

Company & Address Per Week Per Hour Per Earned

FROM TO WEEK MONTH

References & Contacts

Emergency Contact

Name: Relation:
Ahsan Son
Home # Cell#:
3. 4383405544

Page 7 of 9
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.

Current Landlord

Name: Phone#

Would this landlord provide a good reference? Yes____ No____ If no, why?

________________________________________________________________________________

Reasons for move:

Declaration, Waiver and Release Form

I understand that this application does not constitute an agreement on the part of Red Deer Housing
Authority, or its agents, to provide me with rental accommodation. I further acknowledge the right of Red
Deer Housing Authority at any time prior to the execution and delivery of a lease hereby applied for, to
withdraw, revoke or cancel, without penalty or liability for damage otherwise, any acceptance or approval of
this application previously made or given.

I/We ______________________________________________authorize
Syed Sajjad Haider Red Deer Housing Authority to
make any inquiries to verify the facts contained herein by any method deemed necessary, being fully aware
that discovery of any false statement shall cancel any further consideration of my application.

I further understand that it is my responsibility to contact the Red Deer Housing Authority in writing of any
changes in family composition, source of income, gross income assets, employment, and change of address or
any household changes should they occur.

I further understand that it is my responsibility to contact the Red Deer Housing Authority within Six
Months if applying and at least every six months thereafter and that failure to do so will result in the
cancellation of my application and the need to reapply.

_______________________________ _______________________________

Signature of Applicant #1 Signature of Applicant #2

Page 8 of 9
The personal information you provide on this form and any attachments is collected in accordance with the Alberta Housing Act
and the Freedom of Information and Protection of Privacy Act. The information you provide will be used for the purpose of
administering the Community Housing and Rent Supplement Programs to determine and verify your eligibility for any of the
programs, audit, and evaluation. The FOIP Act applies to Housing Management Bodies established under the Alberta Housing Act,
such as the Red Deer Housing Authority. If you have any questions about the collection of this information, please contact Red
Deer Housing Authority Office at (403)343-2177.

STATUTORY DECLARATION

Dominion of Canada )

Province of Alberta ) In the matter of this application for dwelling accommodation/subsidy

To wit:
Syed Sajjad Haider
I/We, ____________________________of the __________ of ________________in the Province of Alberta, do solemnly
declare as follows:

1. I am the applicant named on the said application

2. That the statement made by me in the said application are complete and true in all respects
And I make this solemn Declaration conscientiously believing it to be true and knowing it is of the same force and
effect as if made under oath and by virtue of the “Canadian Evidence Act”.
27 Septem 23
Declared before me at the City of Red Deer, in The Province of Alberta, this _______day of________, 20_______.

____________________________ _____________________ ______________________

A Commissioner for Oaths in and For the Signature of Applicant Signature of Applicant
Province of Alberta

Page 9 of 9
 Syed Sajjad Haider
Applicant Name:_____________________________________________
72 Montee Sagala Ile Perrot j7v3b7
Address:_____________________________________________________
4384935058
Phone Number:_______________________________________________

Questions for verification: List each separately Total for household

Income shown on Line 15000 of your 2021/2022 17197

$_______________
Canada Revenue Agency (CRA) Notice of 6936.46
$_______________
Assessment (NOA), for each household member 22
years of age or older. $_______________
not including live in aids or dependents up to 24 years old who
attends a recognized school or education institution full time. $_______________ 24133.46
$______________
Current rent $750

Do you pay for utilities in addition to rent? Yes ☐

No ☐
Total number of household members
- Adults Number of Adults 2

- Dependents (children up to 24 years of age) Number of Children 1

Please check off any of the following population

groups that apply to members of your household
Indigenous peoples
☐
People with disabilities
☐
Individual fleeing violence or leaving second stage shelter*
☐
At risk of or transitioning out of homelessness*
☐
People dealing with mental health or recovering from addiction*
☐
Youth exiting government care
☐
Veteran
☐
Recent Immigrant or Refugee (in Canada less than 5 years)
☐
Racialized group
☐
Identify with diverse concepts of gender identity and expression or sexual orientation
☐
*Please contact (CLIENT SERVICES) if you check this category. Supporting documentation may be required.

Any additional information that has changed since you applied, for example, currently staying at a
friend’s, current housing is unsafe?______________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________.

September 27 2023
Signature:____________________________________ Date: ___________________________
The personal information collected through Red Deer Housing Authority is for the purpose of application for subsidized housing or rental benefits.
This collection is authorized by section 33(c) of the Freedom of Information and Protection of Privacy Act. For questions about the collection of
personal information, contact 403-343-2177, or mail 302, 4719- 48 Avenue, Red Deer, AB T4N 3T1.