Community Housing and Direct Shelter Subsidy Application Form

Part 1 - Personal Information

Applicant Surname *

First Name *

Date of Birth (m/d/y) *

Preferred Name

Pronouns

He/Him

She/Her

They/Their

Address *

Township/Province *

Postal Code *

Mailing Address*

Same as Above

Mailing Address

Township/Province

Postal Code

Telephone # *

E-Mail *

Member ID # *

Co Applicant Surname

Co Applicant First Name

Date of Birth (m/d/y)

Alternate/Emergency Contact Name: *

Alternate/Emergency Contact Phone #: *

Marital Status:*

single

married

separated

divorced

common-law

Widow

Unit Type:*

single

couple

family (with dependant children)

senior

senior couple

Number of dependants: *

Current Status*

Permanent Address

Homeless

Are you currently on the By Name List?*

Yes

Are you in receipt of the Canada Ontario Housing Benefit (COHB)?*

Yes

Are you a victim of family violence?*

Yes

Safe Contact Name

Safe Contact Phone #

Have you filed your most recent income tax return?*

Yes

Have you been evicted within the last 5 years due to an N6 (Illegal Act)?*

Yes

Do you require a modified/accessible unit?*

Yes

Is a household member confined to a wheelchair?

Yes

Do you have any pets?*

Yes

If yes, how many?

Are any family members living in your house a member of one of the following communities?*

First Nations

Inuit

Mètis

N/A

In which community would you like to live? *

Do you:*

Rent

Own

Number of Bedrooms *

Landlord's Name: *

Is the landlord a family member?*

Yes

Utility Information

Please specify if the following are included as part of rent.

Verification will be requested once your application has been processed/reviewed.

Rent/Mortgage (please specify)*

Rent

Mortgage

Amount paid *

Oil - included in Rent?*

Yes

If oil not included amount paid:

Hydro - included in Rent?*

Yes

If hydro not included amount paid:

Propane/Natural Gas - included in Rent?*

Yes

If propane/gas not included amount paid:

Wood - included in Rent?*

Yes

If wood not included amount paid:

Property Tax*

Yes

Amount Paid (if applicable)

Total Amount of Shelter Costs (include rent): *

Part 3 - Current Household Income (All Sources)

Verification will be requested once your application has been processed/reviewed.

Sources of income

OW Gross Monthly received:

OW Net Monthly received:

ODSP Gross Monthly received:

ODSP Net Monthly received:

Old Age Security Gross Monthly received:

Old Age Security Net Monthly received:

Canada Pension Plan Gross Monthly received:

Canada Pension Plan Net Monthly received:

Child/Spousal Support Gross Monthly received:

Child/Spousal Support Net Monthly received:

Canada Child Tax Benefits Gross Monthly received:

Canada Child Tax Benefits Net Monthly received:

Earnings Gross Monthly received:

Earnings Net Monthly received:

Other income/pension Monthly received:

Other income/pension Net Monthly received:

Please specify type of other income/pension (if applicable)

Total Gross Monthly Income received: *

Total Net Monthly Income received: *

Assets

Amount of Cash on hand: *

Amount of Funds in Bank: *

Amount in GICs:

Amount in Life Insurance (Cash Value):

Amount in RRSPs:

Amount in Collectables:

Amount in Real Estate:

Amount in Other Assets:

Total Amount in Assets: *

Declaration

Declaration Acceptance: *

I/We give consent and authorization to the Manitoulin-Sudbury District Services Board to:

Make any inquiries that it deems necessary to verify the information given in this form (including a credit or landlord check, if applicable) and I authorize any person or Social Agency having knowledge of any such information to release the information to the Manitoulin-Sudbury District Services Board.
Disclose the information given by me to the Manitoulin-Sudbury District Services Board, to any Social Agency providing any form of service to me or to any housing provider associated with the Manitoulin-Sudbury District Services Board.
Information will not be disclosed to any other party, except where allowed by law.

For the purposes of verification of subsidy, it may be necessary to share information pertaining to income, assets, or household composition between departments of the organization. By signing the document, the applicant/tenant agrees to these terms and conditions.

I/We confirm that all information provided is true and correct to the best of my/our knowledge.

Applicant Signature *

Clear

Date (d/m/y) *

Co Applicant Signature

Clear

Date (d/m/y)

For Direct Shelter Subsidy Applicants Only

Direct Shelter Subsidy will be provided monthly (if approved) provided the applicant:

Pay their shelter costs and provides the DSB proof of payment every 6 months.
A tenant is in good standing according to the Residential Tenancies Act

Direct Shelter Subsidy will cease:

The month after Ontario Works or Ontario Support Disability eligibility ceases.
The month the applicant fails to provide proof that shelter costs have been paid.
The applicant moves out of the current residence, in these cases future eligibility for Direct Shelter Subsidy will be based on the new residence and availability of funds within the Direct Shelter Subsidy program.
Upon 60 days’ notice should funding for this Direct Shelter Subsidy program terminate.
The tenant receives a Notice to Vacate for Non-Payment of Rent or an Order to Terminate Residency.

Submit