For help with this form, please contact the SAFER office at 604-433-2218 or 1-800-257-7756 HOU-035 (2024-05-22)
Page 1
Application Form
Submit completed
application with
supporting documents:
Shelter Aid for Elderly Renters
101 – 4555 Kingsway
Burnaby, BC V5H 4V8
Scan and save, then submit
using the Program Upload
Form at:
www.bchousing.org/puf
By fax to (604) 439-4729
The Shelter Aid for Elderly Renters (SAFER) program helps make
rents more affordable for BC seniors with low to moderate incomes.
SAFER provides monthly cash payments to eligible BC residents who
are age 60 or over and who pay rent for their homes.
Who is eligible?
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
for the full 12 months immediately preceding your application.
3. You and your spouse (if applicable) are one of the following:
Canadian citizen(s); or authorized to take up permanent
residence in Canada; or Convention refugee(s).
4. You pay more than 30% of your gross (before tax) monthly
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.
6. You do not receive income assistance through the B.C.
Employment and Assistance Act or the Employment and
Assistance for Persons with Disabilities Act (excluding Medical
Services only).
For more information on eligibility please see the SAFER website at
www.bchousing.org/SAFER or call the SAFER office at 604-433-2218
(or toll-free at 1-800-257-7756).
Benefit Effective Date:
The Benefit is effective the latter of:
➔ The first day of the month in which your application is received by
our office; or
➔ The first day of the month in which you are deemed eligible for
SAFER.
The Benefit is a non-taxable reimbursement for rent already paid and
is paid at the end of each month.
PLEASE:
Print clearly.
Do NOT include original
documents (we require
photocopies only).
Do NOT use staples.
Avoid Processing Delays:
Eligibility cannot be determined
until you provide all required
documentation.
The most common cause of
processing delays is missing
documents.
Applications must:
• Be complete, signed, and
dated
• Include proof of income,
age, and rent
• Include bank information for
Direct Deposit
Applications submitted without
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 (2024-05-22)
Page 2
PLEASE
PRINT
CLEARLY
FOR OFFICE USE ONLY
Date: Status: File:
1. Applicant Information
Last Name
First Name(s)
Age
Gender
Born in Canada? (Yes/No)
2. Spouse or Partner Information (if applicable)
Last name
First name(s)
Age
Gender
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
Revenue Agency, to BC Housing of information from
my/our income tax records, whether supplied by me/us or
by a third party. The information will be relevant to, and
used solely for the purpose of, determining and verifying
my/our eligibility, entitlement for and the general
administration and enforcement of rental
assistance/subsidies from BC Housing.
This authorization is valid for the current taxation year,
the two taxation years immediately preceding the current
taxation year and each subsequent consecutive taxation
year for which I/we have applied for rental
assistance/benefit.
I/we understand that if I/we wish to withdraw this
consent, I/we may do so at any time by writing to:
Manager, Applicant Services
BC Housing, 1701 - 4555 Kingsway
Burnaby, BC V5H 4V8.
I/We do not give consent for the Canada Revenue
Agency to provide my/our income tax information to
BC Housing. I/We understand that I/we will be responsible
for providing verification of my/our income and assets in
order to confirm eligibility for rental assistance/benefit.
I/We have attached the following proof:
o Copy of Notice of Assessment for the last filed
tax year.
o Copy of detailed Income Tax Return for the
last filed tax year.
o If self-employed: Copy of Statement of Business
Activities and all related worksheets (only
required for individuals with self-employment
income, either business or professional on their
tax return).
If you are not able to locate your income documents,
please obtain a Proof of Income Statement (Option C
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 (2024-05-22)
Page 3
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:
Address(es)
From Date
(dd/mm/yyyy)
To Date
(dd/mm/yyyy)
Landlord Name
Landlord Phone #
Current address
4c. If you or your spouse were not born in Canada, please complete the following:
Name
Date moved
to Canada
(dd/mm/yyyy)
Current status in
Canada
Sponsored Immigrants Only
Name of Sponsor
End Date of
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)
Last Name
Given Names
Relationship
to
Applicant
Birth Date*
(dd/mm/yyyy)
Age
Gender*
(M/F)
*Birth Date and Gender 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 (2024-05-22)
Page 4
( ) -
( ) -
( ) -
( ) -
( ) -
( ) -
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
B.C.
Postal Code
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
B.C.
Postal Code
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,
house, townhouse)
I live in a self-contained basement suite
I live in a Manufactured/Trailer/Mobile home
I live with family or friends (other than spouse/common
law partner)
I live in a Housing Co-operative
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 (2024-05-22)
Page 5
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 or Disability Assistance from the province of BC 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
Employment, Seasonal Employment, Family Support, and all other sources)
APPLICANT
SPOUSE
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 (2024-05-22)
Page 6
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.
◼ BC Housing will issue tax slips for annual benefits of $500 or more
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 delays is missing documentation. Applications submitted without all
required supporting documents can be held for a maximum of 90 days.
HOU-035 (2024-05-22)
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
Shelter Aid for Elderly Renters (SAFER) - Application Checklist
HOU-035 (2024-05-22)
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.