
SD3037(10/06/16)
ORIGINAL - FILE COPY - CLIENT
SHELTER INFORMATION
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and
Assistance Act and the Employment and Assistance for Persons with Disabilities Act. The collection, use and disclosure of personal information is subject
to the provisions of the Freedom of Information and Protection of Privacy Act. Any questions about this information should be directed to your local
Employment and Assistance Office.
CLIENT NAME DATE(YYYY MMM DD)
(FOR OFFICE USE ONLY)
GA
RENTING OR INTENDING TO RENT AT THE FOLLOWING ADDRESS
SUITE NO. STREET ADDRESS POSTAL CODE
MAILING ADDRESS (IF DIFFERENT)
START DATE (YYYY MMM DD) for rental of the room or rental unit
We require a rent receipt in addition to this form immediately upon payment of the first month's rent (if your rent is not paid
directly to the landlord by MSD) . All information may be verified. A rent receipt is attached to this form for your convenience.
Rent Receipt
PLEASE COMPLETE EITHER A OR B:
OR
LANDLORD INFORMATION
(B) ROOM AND BOARD (MEALS INCLUDED
)
$ PER MONTH
X
LANDLORD’S SIGNATURE
DATE SIGNED (YYYY MMM DD)
ADDRESS OF LANDLORD AND POSTAL CODE TELEPHONE NUMBER OF LANDLORD
NAME OF REGISTERED OWNER OF THE LAND (PLEASE PRINT)
NAME OF LANDLORD INCLUDING PROPERTY MANAGER, AGENT (IF DIFFERENT)
Date:
Received from:
For the month of:
Rent $ Room and Board $ Security Deposit $
(YYYY MMM DD)
Landlord’s Signature
This form is for Ministry of Social Development information only and does NOT constitute a tenancy agreement
under the Residential Tenancy Act.
POSTAL CODE
(A) CLIENT’S PORTION OF RENTAL AMOUNT
$ PER MONTH
TOTAL RENT (IF SHARED)
$ PER MONTH
ARE UTILITIES INCLUDED IN THE RENTAL RATE?
YES NO
SECURITY DEPOSIT REQUIRED?
YES NO
CLIENT’S PORTION OF SECURITY DEPOSIT
$
NUMBER OF ADULTS AT GIVEN ADDRESS
NUMBER OF CHILDREN AT GIVEN ADDRESS
Note: Cost of room and board should include costs associated with food, maintaining the room,
pro-rated utilities cost, and pro-rated property tax.
MARKET RENT (IF SUBSIDIZED)
$ PER MONTH
CITY/TOWN