Statement of Rent
LEZ-14-V
Complete this form if you want to receive (or continue receiving) the shelter allowance from October 1 of one year to September 30 of the following year. You and your spouse (if applicable) must be in one of the following situations:
You rent a room, apartment or house.
You live with someone you pay rent to.
You live in a mobile home on rented land.
This form gives us information on your rent when you apply for the shelter allowance or when there is a change in your situation during the year.
Enclose this form with your Shelter Allowance Application (LEX-165-V).
2024-06 version – Statement of rent for the period from October 1, 2024 to September 30, 2025
Instructions for fillable PDFs
To complete a PDF onscreen, Adobe Reader must be installed on your computer. Once installed, close the program and follow the steps below.
- Place your cursor on the Fillable PDF Document button and right click to display a menu.
- Select Save link as.
- Save the document to your desktop or the folder of your choice. Do not open the document in the download screen that appears.
- Once the document is saved, right click on it to display a menu.
- Click Open with and select Adobe Reader.
- Complete and save the PDF.