Fill - Free fillable McKelvie Burnside Village Supportive Housing c/o 167 Centre (Dufferin County) PDF form

McKelvie Burnside Village

Supportive Housing

c/o 167 Centre Street

Shelburne, ON L9V 3R8

(519) 925-5452

Approval Date:

COPY OF CANADIAN BIRTH CERTIFICATES OR PROOF OF CANADIAN RESIDENCY STATUS

(i.e. CANADIAN CITIZENSHIP CARD, PERMANENT RESIDENT CARD) FOR ALL MEMBERS OF

THE HOUSEHOLD MUST BE PROVIDED WITH THE APPLICATION.

APPLICANT #1:

Last Name:

First Name:

Social Insurance #:

Date of Birth:

Please select your gender:

Male Female

Address:

City: Province:

Postal Code:

Phone:

Can we contact you safely at this address and phone number?

Yes No

Employer name: Work Phone:

Landlord Name: Landlord Phone:

Landlord Address: Current rent ($):

You must be a Canadian Citizen or have made application for status as a permanent resident or for

refugee protection under the Immigration and Refugee Protection Act (Canada). There must be no

removal order enforceable against any member of the household.

Status in Canada (please check one): Verification must be provided with this application.

Canadian Citizen

Permanent Resident

Refugee Claimant

Removal Order

Other (please specify)

Person to contact in your absence or to act as an interpreter (optional):

Name:

Relationship:

Phone:

Name:

Relationship:

Phone:

APPLICANT #2:

Last Name:

First Name:

Social Insurance #:

Date of Birth:

Please select your gender:

Male Female

Address:

City: Province:

Postal Code:

Phone:

Can we contact you safely at this address and phone number?

Yes No

Employer name: Work Phone:

Landlord Name: Landlord Phone:

Landlord Address: Current rent ($):

Status in Canada (please check one): Verification must be provided with this application.

Canadian Citizen

Permanent Resident

Refugee Claimant

Removal Order

Other (please specify)

Have you ever lived in rent-geared-to-income housing before?

Yes No

If yes, provide details below:

Unit sizes you are eligible for are determined by the number of household members, in accordance

with the County of Dufferin Occupancy Standards Policy.

Check Unit Size Preference:

Bachelor Suite 1 Bedroom 2 Bedroom

Do you require parking?

Yes No

If yes, enter the vehicle make: If yes, enter the licence #:

List all previous addresses for the last 3 years, including when you lived there and the

Landlord's name:

Address:

City: Province: Postal Code:

Occupancy dates:

Landlord Phone:

Landlord Address:

Landlord Name:

Yes No

to:

Subsidized?

Address:

City: Province: Postal Code:

Occupancy dates:

Landlord Phone:

Landlord Address:

Landlord Name:

Yes No

to:

Subsidized?

Address:

City: Province: Postal Code:

Occupancy dates:

Landlord Phone:

Landlord Address:

Landlord Name:

Yes No

to:

Subsidized?

Priority Status Due To An Abuse Relationship

My and/or my family's safety is at risk because of abuse by someone I have resided with in

a familial relationship.

If you check this box, other information will be required to verify. Please contact the

Dufferin County Community Support Services office regarding the necessary documents.

If you have concerns about providing documentation to support your application and/or

your request for Special Priority, please contact the Dufferin County Community Support

Services office at (519) 925-5452.

Do you have any pets?

Yes No

If yes, please describe the type of pet:

No Smoking Policy

McKelvie Burnside Village is a non-smoking housing complex. Tenants who are smokers will not

be disqualified as long as they agree to only smoke outdoors/outside.

I am/we are not smokers.

I am/we are smokers but agree to only smoke outdoors/outside.

ADDITIONAL COMMENTS: (Optional)

It is the applicant's responsibility to notify our office within 10 business days of any changes in

your circumstances.

If we are unable to contact you at the telephone numbers listed on this application, your file will

be cancelled.

Rent

I wish not to disclose my financial information and I/we will pay the market rent for

my/our apartment.

I will complete the following detailed statement of monthly income and assets to be

considered for a rate reduction of the rental rate.

OR:

This detailed statement of monthly income is found separately online. This page does not need to be

completed if you are agreeing above to pay market rent for the apartment. If you wish to be assessed

for a rate reduction, please fill out the document and submit it with this application.

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

Ext. 2503.

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.

Declaration

I declare:

1. I declare that everything I have written in this application is true and that no information that is

required to be given has been withheld or omitted.

2. I understand that all information I give to the McKelvie Burnside Village and its agents will

belong to them and they will give my information to the housing provider agents.

3. I understand that only the people I have listed on this application form may live with me in the

housing.

4. I understand 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.

5. I declare I am in Canada legally.

6. Before I can receive housing, I understand that I must pay back or arrange to pay any money

I may owe to any subsidized housing project.

7. I understand that it is an offence, under appropriate Legislative Authorities for an applicant or

any individual to knowingly obtain or assist a household member to obtain

rent-geared-to-income assistance for which they are not entitled. Such an offence carries

up to $5,000 fine or up to 6 months imprisonment as well as prohibition from re-applying

for assistance for a minimum period of two years. If something on this application is

missing, incorrect, or false, the McKelvie Burnside Village and its agents I have applied to

may request additional information or may cancel my application.

Signatures of all household members:

Name:

Date:

Signature:

Name:

Date:

Signature:

7/16/15

McKelvie Burnside Village - Waiting List Application Questions

Applicant Name:

Contact Name:

Form completed by:

Date:

1. Are you 60 years or older?

Yes No

2. Are you a Canadian Citizen or have proof of Canadian Residency Status

i.e. Canadian Citizenship Card, Permanent Resident Card?

Yes No

3. Do you have a valid OHIP card?

Yes No

4. Are you currently receiving CCAC services or have you in the past?

Yes No

If yes, what services do you get? List/describe below.

If no, are you in need of any help with personal care? Describe below. If you do not have CCAC

services we would refer you to CCAC for an assessment.

Can we forward your name and information for this assessment?

Yes No

Do you need help with any of the following? Please explain.

Bathing? How often?

Dressing? Morning care, evening care, or both?

Incontinence Care?

Are you able to transfer yourself? One or two person?

Mobility concerns? Do you use a walker? Canes? Scooter? Wheelchair?

Need for 24-hour emergency support? I.e. trouble with falls, medical illness, etc.

Other?

7/16/15

McKelvie Burnside Village - Waiting List Application Questions

5. Do you receive or require regular other support services? E.g. Adult day program,

transportation, home help, etc.

6. Are you able to make your own meals?

Yes No

I am interested in Meals on Wheels.

I am interested in Congregate dining.

7. Do you have a car? Would you require a tenant parking spot?

Yes No

8. Are you a smoker? (McKelvie Burnside Village are entirely non-smoking

apartments. Tenants who smoke must smoke outside.)

Yes No

9. We will need you to complete an initial county housing application form

with a copy of the birth certificate or Canadian Residency at the time. Do

you require a subsidy? If yes, further financial paperwork will need to be

provided beyond the initial application form.

Yes No

10. Other relevant information? Please state why you would benefit from the on-site support

offered at the Village.

11. Interested in:

Bachelor 1 bedroom 2 bedroom

When you are done, please print this form, attach all necessary documents, and return it to

McKelvie Burnside Village.

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