Tenant Information – Cree Nation of Chisasibi

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Tenant Information Form

Date

First Name

Middle Name

Last Name

Address

Email

Phone

Phone 2

Beneficiary No.

Band No.

Unit Year

Unit No/Lot

No. of Bedrooms

Rent

Renovations Required

Major Minor None

Program Type

CMHC/Social Band Unit Institutional

Unit Type

Single Family Apartment Bachelor Bungalow Row House Trailer Duplex Triplex Fourplex

Employed

Full-Time Part-Time Seasonal Self-Employed Not Employed

If employed, specify employer

If employed, specify occupation

Other status

Pension Welfare Income Security Employement Insurance Student Income Security & Pension None

Marital Status

Single Married Common Law Divorced Seperated Widow/er

Is spouse co-habiting with tenant?

Yes No

Spouse First Name

Spouse Middle Name

Spouse Last Name

Spouse Date of Birth

Spouse Beneficiary No.

Spouse Band No.

Spouse Occupation

Full-Time Part-Time Seasonal Self-Employed Not Employed

If Spouse employed, specify employer

If Spouse employed, specify occupation

Spouse Other status

Pension Welfare Income Security Employement Insurance Student Income Security & Pension None

Number of dependants (children under 18 regardless of relationship to Tenant)

Dependant 1 First Name

Dependant 1 Date of Birth

Dependant 1 Gender

Female Male

Dependant 1 relationship to Tenant

Dependant 2 First Name

Dependant 2 Date of Birth

Dependant 2 Gender

Female Male

Dependant 2 relationship to Tenant

Dependant 3 First Name

Dependant 3 Date of Birth

Dependant 3 Gender

Female Male

Dependant 3 relationship to Tenant

Dependant 4 First Name

Dependant 4 Date of Birth

Dependant 4 Gender

Female Male

Dependant 4 relationship to Tenant

Dependant 5 First Name

Dependant 5 Date of Birth

Dependant 5 Gender

Female Male

Dependant 5 relationship to Tenant

Dependant 6 First Name

Dependant 6 Date of Birth

Dependant 6 Gender

Female Male

Dependant 6 relationship to Tenant

Dependant 7 First Name

Dependant 7 Date of Birth

Dependant 7 Gender

Female Male

Dependant 7 relationship to Tenant

Dependant 8 First Name

Dependant 8 Date of Birth

Dependant 8 Gender

Female Male

Dependant 8 relationship to Tenant

Dependant 9 First Name

Dependant 9 Date of Birth

Dependant 9 Gender

Female Male

Dependant 9 relationship to Tenant

Dependant 10 First Name

Dependant 10 Date of Birth

Dependant 10 Gender

Female Male

Dependant 10 relationship to Tenant

Number of other people including adult children (all other occupants 18Plus regardless of relationship to Tenant)

Person 1 First Name

Person 1 Date of Birth

Person 1 Gender

Male Female

Person 1 Relationship to Tenant

Is Person 1 on a waiting list?

Yes No

Person 2 First Name

Person 2 Date of Birth

Person 2 Gender

Male Female

Person 2 Relationship to Tenant

Is Person 2 on a waiting list?

Yes No

Person 3 First Name

Person 3 Date of Birth

Person 3 Gender

Male Female

Person 3 Relationship to Tenant

Is Person 3 on a waiting list?

Yes No

Person 4 First Name

Person 4 Date of Birth

Person 4 Gender

Male Female

Person 4 Relationship to Tenant

Is Person 4 on a waiting list?

Yes No

Person 5 First Name

Person 5 Date of Birth

Person 5 Gender

Male Female

Person 5 Relationship to Tenant

Is Person 5 on a waiting list?

Yes No

Person 6 First Name

Person 6 Date of Birth

Person 6 Gender

Male Female

Person 6 Relationship to Tenant

Is Person 6 on a waiting list?

Yes No

Other remarks or comments

Authorization

I Hereby authorize the CNC Housing Department to release the above information in summary form in its reports, studies and funding negotiations.

Visits: 139

Cree Nation of Chisasibi Administrative Center

1 Riverside Drive, P.O. Box 150 • Chisasibi, Qc, J0M1E0

Monday to Friday • 9:00 a.m. to 5:00 p.m.

Phone: (819)855-2878 • Fax: (819)855-2875

info@chisasibi.ca

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