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Homelessness Prevention Program - Housing Assistance Application Form

PART 1: Personal Information

To the Manitoulin-Sudbury District Services Board:

I am applying for emergency assistance under the Homlessness Prevention Program and in support of my application,
I make the following statements:

Applicant Surname: *
Applicant First Name: *
Applicant D.O.B. (d/m/y): *
Applicant Full Address: *
Applicant Telephone #: *
Applicant ID #:
Marital Status:*
Spouse Full Name:
Spouse D.O.B. (d/m/y) :
Children and other dependants:
Have you accessed Homelessness Prevention Program in the past 12 months?*
Are you in receipt of Ontario Works?*
Are you in receipt of ODSP?*
If no other income, skip to Part 3.
Is any family member living in your house a member of one of the following communities?*
First Nations
**Note: please include documentation (i.e. payment stub) if applicant is on ODSP, WSIB, CPP-Disablity

PART 2: Family Income

Applicant: Type of Income *
Applicant: Annual Gross Taxable Income *
Applicant: Income Verified? NOA/NCBS *
Spouse: Type of Income
Spouse: Annual Gross Taxable Income
Spouse: Income Verified? NOA/NCBS
Dependant: Type of Income
Dependant: Annual Gross Taxable Income
Dependant: Income Verified? NOA/NCBS
Total Family Annual Gross Taxable Income *
Total Family Income Verified? NOA/NCBS *
**Note: please include documentation (i.e. copy of most current Notice of Assessment or Child Tax Credit, most current pay stubs)
Have all other reasonable sources of financial assistance have been exhausted?*

PART 3: Situation

I/we are applying for the following assistance:*
Homelessness Prevention: People at risk of homelessness remain housed and have connections to support services. (Housing Retention) 534 
Address homelessness: People who are homeless and chronically homeless obtain and retain housing and support services. (Obtaining Housing/ Services and Supports) 516
Emergency Shelters Solutions 535

PART 4: Additional Information

Is there any other information you would like us to consider?

PART 5: Retention of residence Preventative plan of action

I/We feel the following factors have contributed to my/our situation:
I/We have already done the following to ensure my/our furture financial security:
These are the next steps I/we need to take.
In addition, I/we agree to undertake the following (check all that apply):*
Apply for public housing even where no public housing is available so that I/we will be put on a waiting list. (home owners are exempt)
Budgeting (i.e. referral to Sudbury Credit Counselling)
Energy Saver Programs
Employment Services (i.e. Employment Options)
Food Bank
Local Social Clubs (i.e. Lions Club, Knights of Columbus)
I intend to complete the following actions by (d/m/y):  *

PART 6: Declaration & Consent

Declaration Acceptance: *

I/We understand that emergency assistance will only be provided once all eligibility criteria have been met to the satisfaction of the DSB.


Additionally, I/we understand that this is short-term emergency service which I /we can access only once every 12 months.  


Additionally, I/we hereby consent to the disclosure or exchange or transmittal of information as it relates to my/our request for emergency assistance. I/we also consent for the Manitoulin-Sudbury DSB to collect and keep on file information as it relates to my/our request for emergency assistance.  


I/We are also willing to implement the attached action plan (if applicable).  


I/We agree that signing this document warrants that I/we fully agree with the statements mentioned above and that all information given on this form, to the best of my/our knowledge is true and correct.

Applicant Name: *
Date (d/m/y): *
Co-Applicant Name:
Date (d/m/y):
Notice with Respect to the Collection of Personal Information (Freedom of Information and Protection of Privacy Act & Municipal Freedom of Information and Protection of Privacy Act). This information is collected under the legal authority of the Ministry of Municipal Affairs and Housingand the Ministry of Community of Social Services.