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Health Communities Application Form

PART 1: Personal Information

To the Manitoulin-Sudbury District Services Board:

I am applying for emergency assistance under the Healthy Communities Initiative 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 #: *
Applicant SIN #: *
Marital Status:*
single
married
separated
divorced
common-law
Spouse Full Name:
Spouse D.O.B. (d/m/y) :
Children and other dependants:
Have you accessed Health Communities Fund in the past 12 months?*
Yes
No
Are you in receipt of Ontario Works?*
Yes
No
Are you in receipt of ODSP?*
Yes
No
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
Inuit
Métis
N/A
**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?*
Yes
No

PART 3: Situation

I/we are applying for the following assistance:*
Housing with Related Supports (transportation, furniture, moving costs, provision of first/last month rent, utility deposit, hook-up fees, storage costs)
Other Services and Supports (employment supports, education opportunities, family re-unification, relocations for victims of family violence, peer support, relocation due to uninhabitable premises, furniture replacement due to pest infestation, fire, flood or uncontrollable damage)
Homelessness Prevention (emergency needs, rental or utility arrears, short term payment of rent to prevent eviction, assistance to secure and retain housing; provision of basic necessities - food)

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)
Other:
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.