Momiji Seniors Centre
3555 Kingston Road, Scarborough, Ontario, M1M 3W4
Telephone: (416) 261-6683
Web: www.momiji.on.ca
Momiji Health Care Society is a not-for-profit organization that is funded by the government. The following
data are collected for the purposes of managing the waitlist as well as reporting, program planning, andcommunicating with you. The information on this form is strictly confidential and is solely intended for theauthorized use.

Application Form for Tenancy

Confidential when Completed

1a. APPLICANT (Legal Name)
PrefixMr. Ms. Mrs. (Given Name

Middle Name or Initial

Family Name

Middle Name or Initial

Family Name)

1b. CO-APPLICANT (Legal Name)
PrefixMr. Ms. Mrs. (Given Name)

Co-Applicant’s Relation to Applicant (1a):Do you live with Applicant (1a)?  Yes (No need to fill the residential address on 2b) No

2a. PERSONAL INFORMATION - Applicant
Street No.

Street Address

City

Province

Apt / Unit No.
Postal CodePhone (H):
Phone (C):

Mailing Address (if different from above) and reason

Email Address (I consent to email correspondence):
Gender Male Female

Marital Status

 Other

Date of Birth (DD/MM/YY) Never Married Married Widowed
 Divorced
 Married-Spouse in Institution

Status in Canada Citizen
 Landed Immigrant*If Landed Immigrant, Date Entered Canada (DD/MM/YY)
Language

Written:Spoken: English English Japanese JapaneseAge:
 Common Law
 Separated

 Refugee Claimant

 Other (specify) Other (specify)

Do you have your Power of Attorney (POA, legal representative to make decisions for you) assigned?
 Yes – Co-applicant

 Yes – Alternate Contact

 Yes – Other (Fill #3) No

Personal Care:  Yes – Co-applicant

 Yes – Alternate Contact

 Yes – Other (Fill #3)

 No

Property:-1-2b. PERSONAL INFORMATION – Co-Applicant
Street No.

Street Address

City

Province

Apt / Unit No.
Postal CodePhone (H):
Phone (C):

Mailing Address (if different from above) and reason

Email Address (I consent to email correspondence):
Gender Male Female

Marital Status

 Other

Date of Birth (DD/MM/YY) Never Married Married Widowed
 Divorced
 Married-Spouse in Institution

 Common Law
 Separated

Status in Canada Citizen
 Landed Immigrant
If Landed Immigrant, Date Entered Canada (DD/MM/YY)
Language

Written:Spoken: English English Japanese JapaneseAge: Refugee Claimant

 Other (specify) Other (specify)

Do you have your Power of Attorney (POA, legal representative to make decisions for you) assigned?
 Yes – Applicant

 Yes – Alternate Contact

 Yes – Other (Fill #3)

 No

Personal Care:  Yes – Applicant

 Yes – Alternate Contact

 Yes – Other (Fill #3)

 No

Property:

3. ALTERNATE CONTACT(S) [e.g. POA, Next of Kin, Sponsor, Interpreter] (*Max. 2 each)
Name

Address

Phone 1 (Home / Cell / Business)()

Phone 2 (Home / Cell / Business)()

E-mail (consents to email correspondence)

Relationship to Applicant / Co-applicant (circle)

Name

Address

Phone (Home / Cell / Business)()

Phone (Home / Cell / Business)()

E-mail (consents to email correspondence)

Relationship to Applicant / Co-applicant (circle)

Name

Address

Phone (Home / Cell / Business)()

Phone (Home / Cell / Business)()

E-mail (consents to email correspondence)

Relationship to Applicant / Co-applicant (circle)

Name

Address

Phone (Home / Cell / Business)()

Phone (Home / Cell / Business)()

E-mail (consents to email correspondence)

Relationship to applicant / co-applicant (circle)-2-4. HEALTH INFORMATION
Applicant’s Physician’s Name
Telephone No.

(Address)

Co-Applicant’s Physician’s Name
Telephone No.

(Address)

Do you or your co-applicant have any health concerns or disabilities?
If yes, specify:

 Yes No

For the following, please select those that apply (circle A – Applicant and/or CA – Co-Applicant):TRANSFER Independent (A / CA) With Some Assistance (A / CA) Total Assistance (A / CA)

MOBILITY STATUS
 Fully Ambulatory (A /CA) Wheelchair (A / CA) Other (Please Specify):

 Cane (A / CA) Walker (A / CA) Scooter (A / CA)HEALTH STATUS – Check off all those that apply.
*Note: Momiji is a smoke-free building and a no smoking by-law applies to all areas of the building.
 Alzheimer (A / CA) Arthritis (A / CA)

 Parkinson’s (A / CA) Smoking (A / CA)

 Dementia (A / CA) Diabetes (A / CA) Heart Disease (A / CA) Alcohol (A / CA) Depression (A / CA) Cancer (A / CA) Osteoporosis (A / CA) Stroke / TIA (A / CA) Allergies (A / CA)
List all: Other (A / CA)
List all:Comments

5. SUPPORT SERVICES
Before answering the following questions, please review the attached list (p.6) of support
services that Momiji offers.
1. Tenants of Momiji Senior Residence should be able to live independently with limited external
supports. Do you believe that you (and your co-applicant) can live independently?
 Yes
 No
If no, please specify.
2. Will you need any modifications to your apartment unit (e.g. wider doorways for wheelchairs / walkers,apartment accommodations for wheelchair users, automatic door, etc.)?
 Yes
 No
If yes, please specify:-3-

Write “A” (Applicant) and/or “CA” (Co-Applicant) in the rating box that best describes yourcurrent need for assistance to complete the following activities:
ACTIVITIESRATING
Total
Can’t do thiswithout help

EssentialDailyActivities

SomeMay needassistance

COMMENTS
None
Don’t need
any help

Dressing/Bathing
Cooking meals
Taking medication
Laundry

Tenant
Duties

Shopping for basic
needs
Understanding theobligations of the lease
Cleaning the unit
Safely operating thestove / oven
Paying rent and bills ontime

6. RENT ASSISTANCE REQUEST
The government of Ontario provides rent assistance (subsidy) for your rent payment if your income is below
certain net income (please confirm the eligible income amount with Momiji Client Intervention Worker).
Would you like to apply for Rent Subsidy (from Government of Ontario)?  Yes (Fill #7)

7. FINANCIAL INFORMATION

 No (Skip #7)*Rent-Geared-to-Income (RGI: rent subsidy) applicant(s) only

STATEMENT OF INCOME AND ASSETS – For rent calculation only
*Attach a copy of the newest Notice of Assessment to verify your net income.
Annual Income

Applicant

Co-Applicant

Government Old Age Security

Yes



No

Yes



No

Canada Pension



Yes

No

Yes



No

Other Pension

Yes



No

Yes



No

Other Income (investment interest,dividends, etc.)

Yes

NoYes

NoTotal Net Income (From the mostrecent Notice of Assessment, issuedby CRA)$$

Tax Year (Do you own or partially own
property/properties?

)

Yes

NoTax Year (Yes)
No*Note: Upon signing the lease agreement, RGI tenants will have to agree to not own property (let go of it withincertain period of time if they own). Momiji may require you to submit certain supporting document(s) to confirm
eligibility.

8. Unit Preference (*2-bedroom can be only chosen by 2 occupancy with Market Rent)
1st Choice:  1-bedroom

 2-bedroom

2nd Choice (if any):  1-bedroom-4-

 2-bedroom

9. DECLARATIONS and AUTHORIZATION
I/we understand that tenants at Momiji Seniors Residence (MSR) must be capable of living independently,
and that I/we will be interviewed before my/our application is accepted.
I am / we are aware of the following two sections:(1) While being on the MSR waiting list, I/we must:- express my/our intention to remain on the waiting list at least annually (e.g. annual applicantsurvey);- update my contact information when any change occurs; and- inform Momiji staff if no longer wish to / can remain on the waiting list, which includes applying andmoving to a long-term care home.
(2) At some point in the MSR waiting process, Momiji will require me/us to:- submit the copy of Photo ID (government-issued) and proof of valid status to stay in Canada;- take a specific health assessment, conducted by a Momiji staff;- obtain a specific doctor note from my/our physician at my/our expense, and submit it to Momiji;- [RGI applicant only] submit the proof of income (Notice of Assessment); and,- submit any other necessary information, to determine my/our eligibility to remain on the waiting list
and/or to receive the unit offer.
I/we declare that all the information in this application is correct and hereby authorize Momiji Health Care
Society and its agents to verify any or all of the information contain herein, and to perform a credit check at
its discretion.
I/we consent Momiji Health Care Society collecting such information about me/us as may be necessary todetermine my/our ability to live independently and I/we hereby authorize Momiji Health Care Society toobtain such information from any person, corporation or social agency, including my/our physician andfamily members.
I/we do authorize Momiji Health Care Society to disclose the information given on this form to any social
agency providing any form of social assistance to me and to any source of subsidized rental
accommodation within Metropolitan Toronto (only applicable to applicants who require rent assistance).
Applicant’s signature

Date

Witness (print)

Witness (signature)

Co-Applicant’ signature

Date

Witness (print)

Witness (signature)

If the third party (includes family, friend, POA) other than Applicant / Co-Applicant themselves completed
this form, state the reasons:-5-Support Service Checklist
Our Support Services care team provides support for our tenants to maintaintheir independent living at Momiji. Our team offers the services listed below forMomiji tenants to support your independent living at Momiji once you move in.
Our team will have an initial assessment meeting once you move into Momiji inorder to make the official service contracts to meet your needs.
Personal Care services
Daily Check (phone/visit)
Medication Reminders
Assistance with Bathing / Personal Care
Escorting to Medical Appointments
Light home making services
Light house cleaning
Laundry
Grocery shopping

Transportation services (for Fee)
Medical appointments
Non-medical appointments (grocery shopping, bank, etc.)