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Statement of Rent For The Shelter Allowance

This document is a Statement of Rent for the Shelter Allowance for the period from October 1, 2024, to September 30, 2025, which must be completed by individuals renting a dwelling. It outlines the necessary information required from both the applicant and the landlord, including rent details and any included services. The completed form should be sent with the Shelter Allowance Application to a specified address in Montréal, Québec.

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186 views1 page

Statement of Rent For The Shelter Allowance

This document is a Statement of Rent for the Shelter Allowance for the period from October 1, 2024, to September 30, 2025, which must be completed by individuals renting a dwelling. It outlines the necessary information required from both the applicant and the landlord, including rent details and any included services. The completed form should be sent with the Shelter Allowance Application to a specified address in Montréal, Québec.

Uploaded by

awsss5
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Notice L E Z-14-V (2024-06)


E

Statement of Rent for the Shelter Allowance 2024 Erase

Do you need this form? Completing the form


Complete this form if you rent a dwelling. You need it to provide information Situation Parts to complete
about your rent if you are claiming the shelter allowance for the period
from October 1, 2024, to September 30, 2025, or if your situation changed You are enclosing a copy of your • Complete only Part 1.
during the year. The rent in question can be paid for any of the following: lease or the renewal notice (if you
• a rented room, apartment or house received one) with your application.
• a mobile home on rented land You either do not have a lease or • Complete Part 1.
are not enclosing a copy of your • Have the landlord or person
Do not file this form if you own your dwelling. lease or renewal notice. you pay rent to complete and
sign Part 2.

Send this statement of rent with your Shelter Allowance Application (LEX-165-V).
Send this statement of rent to the following address: C. P. 6800, succursale Place-Desjardins, Montréal (Québec) H5B 1J5.

1 Part to be completed by you (the applicant)


Last name First name
1 2
Apartment Street number Street or PO Box
3
City, town or municipality Province
Province Postal code
4 5
Area code Phone
6

7 Type of dwelling for which you pay rent (check one)


1 rented room
2 rented apartment or house
3 mobile home on rented land
Total rent for October 2024 or current rent (if you are applying after October 2024) ��������������������������������������������������������������� 8

Is heating included in your rent?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Yes No


Is electricity included in your rent? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Yes No
Are the following services included in your rent: personal hygiene, meals or housecleaning? . . . . . . . . . . . . . . . . . . . . . . . . 11 Yes No

2 Part to be completed by the landlord (or the person to whom the rent is paid)
Make sure the information in Part 1 is accurate and complete, and then complete and sign this part.
Name of landlord (last name and first name, in the case of an indiviual) or last name and first name of the person to whom the rent is paid

Address of the landlord or the person to whom the rent is paid Postal code Area code Phone

Certification by the landlord or the person to whom the rent is paid


I certify that the information in this form is accurate and complete.
Area code Phone Extension
12
Signature of the landlord, the landlord’s representative Date
Date
or the person to whom the rent is paid
Validate Print

160G ZZ 49544871 Prescribed form

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