Detailed Statement of Monthly Income and Assets
(NOTE: Proof of income/assets will be required for rent reduction.)
Statement of Income: Applicant #1 Applicant #2
Old Age Security
Provincial Guaranteed Annual Income System (GAINS)
Canada Pension Plan (CPP)
Old Age Pension - Other Countries
Workers' Compensation/Other Disability Pensions
Department of Veteran's Affairs Allowance
Private Pensions (Specify)
Employment Income (salary, overtime, shift differential,
bonuses, tips, commissions, etc.)
Ontario Works (OW)
Ontario Disability Support Plan (ODSP)
Alimony/Support/Child Support
Employment Insurance
Annuities/RIF Payments
Other Income (Specify)
Total Income:
Statement of Assets: Applicant #1 Applicant #2
Bank, Trust Company, Credit Union, other accounts
(saving and chequing)
Stocks, Bonds, GIC's, Debentures and other securities/
saving certificates
Business Assets (e.g. Partnership, self-employment,
franchise, etc.)
Money owed to you or other persons listed on application
Assets transferred (if you or any other person on this
application have transferred assets in the last 36
months, please specify)
Net value of real estate owned (e.g. house, cottage,
mobile home, land, etc.)
Other assets (specify)
Total Assets: