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
Follow the instructions below before clicking the Fillable PDF Document button at the bottom of the page.
- If you have already opened the fillable form, close it without saving it.
- Download Adobe Reader. If the software is already installed on your computer, go directly to step 4. If you don't want to install Adobe Reader, click the PDF Document button, print the form, complete it by hand and mail it to us.
- After downloading and installing Adobe Reader, close it.
- Place your cursor on the Fillable PDF Document button at the bottom of the page 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.
- Follow the instructions to file the form.