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Community Housing and Direct Shelter Subsidy Application Form

Applicant First/Last Name *
Member ID:
Applicant D.O.B.: *Date of Birth (d/m/y)
Applicant Gender: *
Applicant Full Address (Street #, Town, Postal Code): *
Applicant Telephone #:
Applicant Mobile #:
Applicant Email: *
Alternate/Emergency Contact Name: *
lternate/Emergency Contact Phone #: *
Applicant Marital Status:*
single
separated
common-law
divorced
married
Family Unit Type:*
single
couple
family (with dependant children)
senior
senior couple
Number of dependants:
Dependent #1 Name:
Dependent #1 D.O.B.: Date of Birth (d/m/y)
Dependent #2 Name:
Dependent #2 D.O.B.: Date of Birth (d/m/y)
Dependent #3 Name:
Dependent #3 D.O.B.: Date of Birth (d/m/y)
Dependent #4 Name:
Dependent #4 D.O.B.: Date of Birth (d/m/y)
Dependent #5 Name:
Dependent #5 D.O.B.: Date of Birth (d/m/y)
Is the address listed your permanent address?*
Yes
No
Are you currently homeless?*
Yes
No
Are you a victim of family violence?*
Yes
No
Have you been evicted within the last 5 years due to an N6 (Illegal Act)?*
Yes
No
Do you require a modified/accessible unit?*
Yes
No
If yes, provide details:
In which community would you like to live?
In which preferred community housing building do you wish to reside?
Is any family member in your house a member of one of the following communities?*
First Nations
Inuit
Mètis
N/A

Current Living Information

Landlord's Name: *
Is the landlord a family member?*
Yes
No
Monthly Rent: *
Number of bedrooms: *

Utility Information

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

Oil - included in Rent?Amount paid monthly
Yes
No
If oil not included amount paid: Amount of oil paid monthly
Hydro - included in Rent?Amount paid monthly
Yes
No
If hydro not included amount paid: Amount of hydro paid monthly
Propane/Natural Gas - included in Rent?Amount paid monthly
Yes
No
If propane/gas not included amount paid: Amount of propane/gas paid monthly
Wood - included in Rent?Amount paid monthly
Yes
No
If wood not included amount paid: Amount of wood paid monthly
Total Amount of Shelter Costs (include rent):

Current Household Income 

Include all sources of income and assets as listed below.

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.
Total Gross Monthly Income received: Add all above gross monthly amounts.
Total Net Monthly Income received: Add all above net monthly amounts.

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: Add all above asset amounts.

Declaration 

 

Declaration Acceptance: *

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

  1. 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.
     
  2. 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.
     
  3. 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 Name: *
Date: *Date application signed (d/m/y)
Co-Applicant Name:
Date: Date application signed (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.
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