Application for Housing DISTRICT OF COCHRANE SOCIAL SERVICES ADMINISTRATION BOARD HOUSING SERVICES ACCESS For Office Use Only: Primary Provider: _____________________________________________________________________ Date application Received: _______________ Time: __________ Received By: ____________________ Please indicate if you are interested in: a) Rent Geared to Income (Subsidized Rent) Yes ________ No ________ b) Market Rent (Non-subsidized Rent) Yes ________ No ________ c) Number of Bedrooms required ___________ This copy will serve to acknowledge receipt of your application by the District of Cochrane Social Services Administration Board, Housing Services Access, and to acknowledge that your application is: Complete or Incomplete. If “Incomplete” is circled, please fill in the highlighted areas on the application and / or provide the missing information, as requested. If “Complete” is circled, retain this for your records. If you have any questions, please call the Housing Services nearest you. PLEASE READ THE FOLLOWING, COMPLETE THE NAME AND ADDRESS BELOW THEN YOUR SIGNATURE IS REQUIRED COLLECTION OF PERSONAL INFORMATION CLAUSE Personal information contained on this form or in attachments, including form 1, is collected by the District of Cochrane Social Services Administration Board pursuant to Sections 162, 163, 164, 165 and 166 of the Social Housing Reform Act, 2000, and will be used to determine suitability and eligibility for housing applied for, continuation of housing and the appropriate rent scale and rent-geared-to-income charge. Personal information may be released to the housing provider, the government of Canada, including Canada Customs & Revenue Agency, other municipal/provincial and federal departments and agencies who assist in the provision of affordable housing and to social agencies and government agencies providing social assistance to the tenant. The tenant consents to the verification, disclosure, and transfer of information given on this form and attachments by or to any of the above entities and will provide any required supporting material. Questions about this collection should be directed to the Housing Services of the District of Cochrane Social Services Administration Board. Freedom of Information Contact Person: Barb Millions, Ontario Works Supervisor, Suite 120, 38 Pine St. N., Timmins, ON P4N 6K6 Declaration I/we make the above, the following and all other, whether verbal or written, representations, to the District of Cochrane Social Services Administration Board Housing Services, knowing that they will be relied upon by the District of Cochrane Social Services Administration Board Housing Services and its member-housing providers, to assess by qualifications for rental subsidy accommodation and to establish rent. 1. I have read the definition of Income and Gross Family Income on the following page and I fully understand them. 2. The information given on this form is accurate and complete as requested. 3. I understand that if rental subsidized accommodation is provided to me, that accommodation is to be occupied only by myself and “those persons listed in the STATEMENT OF HOUSEHOLD COMPOSITION” subject to approval. I give consent and authorization to the District of Cochrane Social Services Administration Board Housing Services 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 District of Cochrane Social Services Administration Board Services. 2. Disclose the information given by me to the District of Cochrane Social Services Administration Board Housing Services, to any Social Agency providing any form of service to me or to any housing provider associated with the District of Cochrane Social services Administration Board Housing Services. 3. Information will not be disclosed to any other party, except in accordance with provisions of the FIPPA, MFIPPA, PHIPA, PIPEDA. 4. For the purposes of PHIPA, I give consent for the collection of health information to District of Cochrane Social Services Administration Board Housing Services for the purpose of assessing eligibility. The consent is valid until all matters relating to eligibility are resolved to the satisfaction of the District of Cochrane Social Services Administration Board Housing Services. 5. The District of Cochrane Social Services Administration Board Housing Services voluntarily complies with the Federal Privacy Information Protection and Electronics Documents Act 2000 (PIPEDA), which applies to the standards for personal information with respect to commercial activity. Applicant Signature Date Witness Signature Co-Applicant Signature Date Witness Signature Co-Applicant Signature Date Witness Signature Name: ________________________________________________ Address: _____________________________________________________________________________ MINUTEMANPRESS50200-2Z55 Page 1 of 11 Definition of Income “Income” means all income, benefits and gains, of determined, an imputed rate of return set by the every kind and from every source including, but not Ministry of Housing from time to time; limited to the following: j) the gross interest income from savings or chequing a) gross salaries, wages, overtime payments, accounts in a bank, trust company or a credit union; commissions, bonuses, tips, gratuities; k) the gross amount of interest earned or payable from b) grants, scholarships or bursary payments; bonds, debentures, term deposits or investments, c) the greater of the net income from the business or certificates, mortgages, capital gains or lump sum the total withdrawals from the business as personal payments or other assets; salary or other benefits of anyone who is self- l) an imputed income equal to the total appraised value employed in a business; of all assets which do not produce interest income d) the gross amount of unemployment insurance multiplied by a rate of return set by the landlord benefits; from time to time. e) the gross amount of workers’ compensation payments or other industrial accident insurance “Gross Family Income” means the aggregate income payments made because of illness or disability; of: f) the gross amount of any old age security, federal 1) the tenant and every person residing in the leased guaranteed income supplement and spouse’s premises; allowance and financial assistance under the Ontario 2) every tenant on the lease temporarily resident Guaranteed Annual Income System (GAINS); elsewhere. g) the gross amount of every kind of pension, allowance, benefit and annuity whether from a “Spouse” means: federal, provincial or municipal government of 1) a couple who are married to one another or who Canada or any level of government of any other represent that they are married to one another; country or state or from any other source; 2) a couple who not being married to one another, h) the gross amount of alimony, separation, evidence an intention to cohabit in a relationship of maintenance or support payments; permanence or represent to the landlord that they i) the gross amount of gains from investments intend to do so. including interest on dividends, stocks, shares other securities, and where the actual income can not be Examples of Possible Sources of Income Employment • Full-time • Seasonal • Disability Pay • Cost of Living Bonuses • Part-time • Odd Jobs • Overtime Earnings • Sickness Pay • Irregular • Shift Bonuses • Commissions • Long Term Income Protection • Casual • Yearly/Seasonal Bonuses • Tips and Gratuities Payments • Separation / Vacation Pay Self-Employment • Tutoring • Child Care • Taxi • Music Teaching • Babysitting • Business Pensions and Allowances • Old Age Security (OAS) • Widow’s Pension • War Veteran’s Allowance (D.V.A.) • Guaranteed Income Supplement (GIS) • Company Pension • War Veteran’s Allowance (other countries) • Ontario Disability Support Plan (ODSP) • Private Pension • Military or Militia or Civil Defense Allowances • Canada Pension Plan (CPP) • Public Service Pension • Canada Manpower Retraining Allowance • Quebec Pension Plan • Civilian War Pension • Training Allowances • Social Security (other countries) • Disability Pension • Retraining Allowances Other • Payments from Official Guardian or Public Trustee • Separation Payments • WSIB • Alimony Payments • Insurance Payments • Support Payments (for spouse or child) • Provincial or Municipal Payments (O.W.) • Support from relatives or other sources • Unemployment Insurance Commission Payments • One-time lump-sum payments (inheritances, court and • Payments under Compensation for Victims of Crime Act out of court settlement) • Payments from Children’s Aid Society or Catholic • Mortgage Income Children’s Aid • Student Grants Income Producing Assets Non-Income Producing Assets • Farm property which produces income • Life Insurance (with a cash surrender value) • Real Estate (residential, commercial, farmland, cottage, • Registered Retirement Savings Plan mobile home) which produces rental income • Real Estate (house, condominium, summer cottages, farmland, commercial or vacant land) • Savings Accounts (bank, trust company, credit union), • Collection of, or investments in other valuable non- annuities, Guaranteed Investment Certificates, stocks or income producing assets shares, bonds, debentures, mortgages, loans, notes, term deposits • Licence which produces income (e.g. Taxi Licence) • Business interest