Fillable Housing Stability Application (Dufferin County)

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Housing Stability Application (Dufferin County)

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The Housing Stability Application (Dufferin County) form is 16 pages long and contains:

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  • 7 check-boxes
  • 166 other fields

Country of origin: CANADA
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Housing Stability Application
Individuals and families in Dufferin County in receipt of Ontario Works (OW) or Ontario Disability
Support Program (ODSP), and Low-Income earners, may be eligible to access financial support to secure
or maintain housing through the Housing Stability Program.
Applications can be submitted in person at the address below or by emailing to hst@dufferincounty.ca
Eligible expenses include:
Last month’s rent
Rental arrears
Hydro
Gas
Water
Heating fuel
Applicant(s) will need to complete the Housing Stability Application and provide supporting
documentation as requested on page 3.
Eligibility will be determined using the following criteria:
• Must be a current resident of Dufferin County;
• Household income must fall within the Low-Income Measure (LIM);
• Income must be able to support accommodations, that are affordable under program
guidelines
• Accommodations must be within Dufferin County
• Utility bill or rental information must be in the applicants’ name
• Approval will depend on the availability of funding
If applying for financial assistance regarding Hydro One or Enbridge Gas Arrears, you are
required to complete an intake with United Way Simcoe Muskoka LEAP Program 1-855-487-
5327.
• United Way Simcoe Muskoka will forward your intake to this office and an appointment will
be made with you to sign all necessary documents.
• United Way Simcoe Muskoka LEAP representative will make final determination of eligibility.
Utility providers/ landlords will be notified of your application for Emergency Financial Assistance as
per the applicable consent provided.
Page 2 of 11
1. Applicant Information
Name of Applicant:
Date of Birth:
Gender:
Address:
Street Address
Unit
City
Postal Code
Phone #: (H)
(W)
Other Contact #:
Veteran Status:
Y / N
Indigenous Status:
Y / N
Citizenship:
Referral from (where did you hear about this program):
2. Household Composition – additional members in the household
Name
Relationship to
Applicant
Date of Birth
(DD/MM/YYYY)
Gender
1)
2)
3)
4)
5)
6)
3. Household Income Information
Employment income (pre-tax)
Documentation required
Applicant:
$
Other household member(s):
$
Support Payments
Employment Insurance
$
Ontario Works
$
Ontario Disability Support Program (ODSP)
$
Child Tax Benefit
$
Canada Pension Plan
$
Ontario Student Assistance Program (OSAP)
$
Loss of Earnings (WSIB)
$
Other (please specify):
$
Other household member’s other income:
$
Other (monthly):
$
Total Monthly Income:
$
Total Annual Income:
$
Page 3 of 11
5. Check List of Required Documents and Signatures
Application is complete when all required documents are submitted
1 pieces of identification for applicant & spouse and children (Birth Certificate, Drivers Licence etc.)
Current utility bill and/or Disconnect Notice (if applying due to utility arrears)
N4 – Notice to Terminate Tenancy or NTA – Notice to Appear (if applying due to eviction / rent arrears)
Rental Promise Note/Lease Agreement (if applying for First/Last Month’s rent)
Pay Verification (one month of pay stubs for each applicant)
Bank statements for most recent 30 days or as requested. Tax return may be submitted for OESP only
Accommodation expenses including rent receipts and utilities bills
Proof of income from all other sources
Required Signatures
Page 4 and/or 5 of the application to apply for assistance
Page 6 of the application to provide consent to the County to share and confirm information
Pages 7 to 12, if applicable, to share and confirm information with your landlord/utility provider
4. Reason(s) for current arrears & request for assistance
High Heating Costs
Job Loss
Illness
Pending EI
Marital Breakdown
Other (provide details):
Grant requested:
$
Page 4 of 11
6. Description of Why You Are Making An Application for Financial Assistance
(Use this section to explain your request and remember to include your signature)
____________________________________________________ _____________________________________________________
Applicant Signature Date
____________________________________________________ _____________________________________________________
Signature of Spouse or Partner Date
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Page 5 of 11
HOUSING STABILITY PROGRAM
Consent to Disclose and Verify Information
(Please complete one consent for family members over the age of 18)
I,______________________________________, an applicant for the Housing Stability Program, and
I,_______________________________________, spouse or partner of the above applicant (complete name only where
applicable) , consent to the Director or the designated representative of the County of Dufferin Community
Services that:
1. I acknowledge that any and all information shared and obtained pursuant to this agreement shall be used
specifically and exclusively for the purpose of determining my/my spouse’s/ partner’s eligibility for assistance
from the Housing Stability Program.
2. The County of Dufferin Community Services be authorized to secure information in respect of any
accommodation, employment or personal verification for said eligibility.
3. The County of Dufferin Community Services be authorized to exchange information with utility providers,
landlords, any agency, Ministry or department of the foregoing; communicating with my/my spouse’s/partner’s
employer(s), utility provider, landlord and/or agency.
4. I understand that this consent will apply to inquiries made relating to my current eligibility for, as well as any past
or future applications to the Housing Stability Program.
5. I further understand that enquires may take the form of electronic data exchanges.
6. I understand that my information will be stored electronically in HIFIS (Homeless Individuals & Families
Information System).
I consent to the sharing of my electronic information with other service providers in Dufferin
County for the purpose of Housing Stability. Please complete HIFIS Consent with your worker.
I fully understand the nature and purpose of this consent and give my consent and authorization voluntarily.
Dated at: Orangeville, this ___________ day of_____________________20_____
(Month)
Signature of Applicant _________________________________________________________________________________________
Signature of Spouse or Partner ___________________________________________________________________________
Signature of household member 18 years or older ________________________________________________________
Signature of household member 18 years or older ________________________________________________________
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)
The information is collected under the legal authority of the Municipal Freedom of Information and Protection of Privacy Act for the
purpose of ensuring a high quality delivery of the Housing Stability Program provided by the County of Dufferin.
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Page 6 of 11
Consent - Personal and Confidential Information EGD LEAP
Enbridge Gas Distribution Inc. – Low Income Energy Assistance Program
BACKGROUND: The Ontario Energy Board’s Low-income Energy Assistance Program (“LEAP”) consists of emergency
financial assistance, special rules and energy conservation programs for qualified low-income customers. To access the
LEAP, you must be qualified by a social service or government agency. The agency will advise your natural gas provider
(Enbridge Gas Distribution Inc. or “Enbridge”) which LEAP benefits you are qualified to receive. The customer listed as the
account owner in the gas provider’s records (refer to your bill) must complete and submit this consent.
CONSENT: I am the customer of record for the gas account number _________________________________________________ at:
____________________________________________________________________________________________
(street address) (Unit/Suite) (City) (Postal Code)
and I am authorized to consent to the disclosure and use of the information described below.
My personal and confidential information that may be disclosed and used includes: my name, address, gas account number,
information on my gas consumption and my gas account (including charges), approval or refusal of LEAP benefits and
approved grants, information contained in the LEAP Emergency Financial Assistance application and supporting
documentation, and information provided to Enbridge by a social service agency or government agency related to the LEAP
Program.
I consent to Enbridge using my personal and confidential information to: (i) determine if I qualify as an “eligible low-income
customer” under the LEAP; and (ii) administer and operate Enbridge’s LEAP. If I qualify as an “eligible low-income customer”
I agree that my Enbridge gas account will reflect my low-income status for 2 years so I can access the special service rules
under LEAP during that time period.
Enbridge contracts with third parties including The County of Dufferin for services related to the LEAP Program, such as
intake and administration of the LEAP Program, delivery of low-income energy conservation programs, and billing and call
centre support. From time to time, Enbridge may need to share some of your personal and confidential information with
these third parties for the purposes identified above and in order to serve your needs. In some instances, such third parties
may communicate directly with you (for example, for LEAP energy conservation programs). Any third party that we share
your personal and confidential information with is contractually bound to keep the information confidential and secure and
to refrain from using it in any way other than is necessary to perform the services.
I consent to Enbridge disclosing my information to such third parties. I certify that I am at least 18 years of age.
Agreed to this ________ day of ______________________, 20______
______ _______________________________
Signature of person giving consent Witness signature
______ ________________________________
Print Name Print Name
Please return completed form to: The County of Dufferin Fax: 519-941-0271
ENBRIDGE GAS – Consent to Disclosure of Personal Information
Required if applying for financial assistance with Enbridge Gas Arrears
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Page 7 of 11
I, the undersigned, affirm the information provided is true. I acknowledge that should any information provided
be found not to be true, I will not be eligible for LEAP Emergency Financial Assistance. I understand that payment
of funds is not guaranteed, even if preliminary approval is granted. If my bill is in excess of the LEAP Emergency
Financial Assistance grant, I agree to make a payment arrangement with my service provider for the balance. I
understand that if I fail to make payments, which I have agreed to pay directly to my service provider, my utility
service may be disconnected and I may not be eligible for future LEAP Emergency Financial Assistance. I have
read, understood and agree to these conditions and requirements.
√ Applicant Signature
Date
Worker’s signature
ORANGEVILLE HYDRO - Service Agreement
Required if applying for LEAP financial assistance with Orangeville Hydro Arrears
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Page 8 of 11
Pursuant to the Personal Information Protection and Electronic Documents Act (S.C. 2000, chapter 5, as amended)
and the applicable Freedom of Information and Protection of Privacy Acts, I ______________________________________
(insert first name, middle initial, last name)
grant my consent to County of Dufferin Community Services to disclose my personal information under the
terms and conditions set out below to evaluate eligibility for the following:
LEAP Emergency Financial Assistance
Service Provider customer service measures
The following energy conservation programs:
1. The personal information that may be disclosed is as follows:
(a) Information relating to the status of my account, number
(hereinafter referred to as “my account”)
with
Orangeville Hydro
relating to consumption at:
(street address)
(Unit/Suite)
(City)
(postal code)
2. The personal information may be disclosed to the following persons and/or organizations:
(a)
Housing Stability Program
and,
(b)
Any other representative of
County of Dufferin Community Services
(insert Agency name – if none insert “None”)
(c)
Any other representative of
“GreenSaver” Home Assistance Program
(insert name of energy conservation program” – if none insert “None”)
(d)
Any other representative of
County of Dufferin Community Services
(insert Social Service Agency name– if none insert “None”)
3. The consent to disclose my personal information referred to above shall expire on ____________________________.
(insert date not less than 30 days after the date of the signature)
4. I certify that I am at least 18 years of age.
√ Signature of person giving consent
Witness signature
Date
Date
***The above customer is classified as “low income” under the LIM chart. Please designate this customer
as low income in your records.
ORANGEVILLE HYDRO - Consent to Disclosure of Personal Information
Required if applying for financial assistance with Orangeville Hydro Arrears
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Page 9 of 11
HYDRO ONE - Consent to Disclosure of Personal Information
Required if applying for financial assistance with Hydro One Arrears
***The above customer is classified as “low income” under the LIM chart. Please designate this customer
as low income in your records.
The County of Dufferin
The County of Dufferin
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Page 10 of 11
Rental Promise Note
Required if applying for financial assistance with First and/or Last Month’s rent
When an application is being submitted requesting financial assistance with First and/or Last Month’s rent this
Rental Promise Note will need to be completed by Landlord. A Community Services Worker will be contacting the
Landlord and explain process. Please be advised that this is a one-time grant. The applicant for this program will
need to demonstrate that they can afford the unit.
I, _______________________________________________________________________________________________________________ of
Name of Landlord
___________________________________________________________________________________________________________________
Address – Postal Code
Will Rent ____________________________________________________ On ________________________________________________
Room, Apartment, House Date to Move In
To: ___________________________________________________
Name of Tenant
Rent: $ __________________ Per ______________________________
Day, Week or Month
# of Bedrooms ① ② ③ ④ ⑤
Utilities Included: Y N
Address of Rental Accommodation (if different from above)
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
Amount Required: $ _______________________ to Move In
________________________________________________ ________________________________________
Signature of Landlord/Agent Date
________________________________________________ ________________________________________
Residence Phone No. Bus. Phone No. 8:30 a.m. – 4:30 p.m.
Page 11 of 11
Emergency Services – Contact Numbers
OPP
1-888-310-1122
Emergency Crisis Lines
Crisis Line (Community Torchlight)
1-877-822-0140
Caledon/Dufferin Victim Services
1-888-743-6496
Dufferin Child & Family Services
519-941-1530
Family Transition Place
519-941-4357
Centre for Career and Employment Georgian College
519-942-9986
Choices Youth Shelter
519-942-5970
County of Dufferin Community Services Housing Stability
519-941-6991
County of Dufferin Community Services Housing Application
519-941-6991
Family Transition Place
519-942-4122
Salvation Army New Hope Community Church
519-943-1203
Canadian Mental Health Association Peel Dufferin
1-844-437-3247
Orangeville SPCA
519-942-3140
Food Banks
Orangeville Food Bank
Tuesday 10am – 12:30pm Wednesday 6 pm – 8pm Thursday 12pm – 4pm
519-942-0638
Shelburne Food Bank
519-925-2600
Grand Valley Food Bank
519-928-2258
Salvation Army Food Bank - Monday & Friday by appointment
519-943-1203
Dundalk Food Bank
519-923-0454
General Information and Referral Help to Community and Social Services - Dial 211
General Information on services for Parents, Children and Youth visit
the Dufferin Family Directory www.dufferinfamilydirectory.org
Services Available from Monday to Friday during office hours
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Housing Stability Application (Dufferin County)

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Completed 5 July 2022

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