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Statement of Rent – 2022

Complete this form if you want to receive (or continue receiving) the shelter allowance for the period from October 1, 2022, to September 30, 2023. One of the following situations must apply to you and your spouse (if applicable):

  • You rent a room, apartment or house.
  • You live in a mobile home on rented land.

Depending on your situation, you may have to enclose this form with your Application for the Shelter Allowance – 2022 (LEX-165-V).


To complete the form, save it to your computer and open it in Adobe Reader.

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2022-09 version

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