McKelvie Burnside Village Housing
Declaration and Consent
Please read this release and consent form carefully, and sign in the spaces below. All
applicants must sign this Release and Consent.
1. I understand that McKelvie Burnside Village and its related agents to whom I am applying for
for housing are authorized to collect personal information about me in accordance with
various Legislative Authorities. Any questions about the collection of my personal
information should be directed to the Clerk/Director of Corporate Services (519) 941-2816
2. I understand and agree that the McKelvie Burnside Village and its agents will use the
information I give them:
• to find out if I qualify for the housing I have applied for.
• to find out if I continue to qualify for the rent-geared-income assistance and/or special
needs housing, and
• to find out how much assistance I am eligible for.
3. I consent to the McKelvie Burnside Village and its agents giving the information on this form,
and any attachments, to the social services offices, other municipal service managers or
district social services administration boards and housing providers without further notice to
me. I understand that this will be done if the information is necessary to make decisions or
verify my eligibility for assistance under any income support program.
4. I consent to the release of any information to the McKelvie Burnside Village and its agents
about any bank account, safety deposit box, assets of any nature or kind held by me, or on
my behalf, or by or on behalf of any of my dependants or children temporarily in my care,
alone or jointly with any other person in any financial institution.
5. I consent to the McKelvie Burnside Village and its agents giving the information on this form
and any attachments to the Government of Canada, a department, ministry, or agency of it,
without further notice to me, if the information is necessary for the purpose of administering
or enforcing the Income Tax Act (Canada) or the Immigration Act.
6. I consent to the McKelvie Burnside Village and its agents giving the information on this form
and any attachments to any government or agency or individual with whom the McKelvie
Burnside Village and its agents has made an agreement under the Social Housing Reform
Act, 2000, without further notice to me, for the purpose of conducting research related to a
social benefit program or social housing or rent-geared-to-income assistance program.
7. I understand that any information on this form and any attachment given by the McKelvie
Burnside Village and its agents to a body listed above is confidential and will only be given
in accordance with appropriate Legislative Authorities.
See next page for Declaration.