Fillable Residential Services Application/Referral - Part 1 (City of Ottawa)

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Residential Services Application/Referral - Part 1 (City of Ottawa)

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Residential Services Application/Referral - Part 1
Community and Social Services
Community Supports
CS-RS 893E
Part 1- Applicant Information (Form CS-RS 893E)
Residential Services, also known as domiciliary hostels, are private or non-profit residences that provide long-
term housing to vulnerable adults who require some supervision and services to maintain their independence
in the residence. Services include: furnished rooms, 24-hour urgent response, medication management, meals
and snacks, housekeeping and personal laundry, social and/or recreational activities.
Overview :
To apply for a Residential Services subsidy, a person must complete an application form. The application is
divided into two parts:
If you are unable to print the application (Part 1- Applicant Information and Part 2 - Health Information), you
may request a paper copy by e-mailing CommunitySupports@ottawa.ca
or by calling 613-580-2424, extension
26586 and one will be mailed to you.
Read the Instruction Guide (Form CS-RS 892E) found on ottawa.ca before completing the
application form. The guide provides detailed information and step by step instruction
on how to fill out the application.
Send the completed application to the City of Ottawa Community Supports
Once you have both the Applicant Information (Sections 1A to 1E) and the Health Information (Sections 2A to
2D) completed, submit both forms to Community Supports by e-mail, fax or mail.
E-mail (scan copy): CommunitySupports@ottawa.ca
Fax: 613-580-2790
Mail: Community Supports, 370 Catherine Street, Ottawa, ON K1R 5T5
Page 1 of 7
• Part 1: Applicant Information (Form CS-RS 893E)
• Part 2: Health Information (Form CS-RS 894E)
• The applicant must consent to the release of information by completing and signing
Section 2A of the Health Information form
• Sections 2B to 2D must be completed by a health care professional such as a
doctor (for example family doctor, psychiatrist, neurologist), nurse or social worker.
Residential Services Application/Referral - Part 1
Community and Social Services
Community Supports
CS-RS 893E
E-mail address:
Phone number:
Postal code:Province:City:
Address:
Mailing address if different from residence address
Apartment / unit
number :
Are you able to communicate in English or French? Select those that apply : English French
Do you require an interpreter /
translator?
YesNo
If yes, please specify language:
Language(s)
Interpreter / translator
Postal code:Province:City:
Address:
Next of kin or emergency contact
Apartment / unit
number :
Last name:First name:
Section 1A - Personal information
Last name:First name:
Date of birth (DD/MM/YYYY):
Male
Female
Gender
Social Insurance Number:
Health Card Number:
Version code (for example 1234 5678 9123 GB):
Living conditions:
Home owner Renting
Other
Specify :
Postal code:Province:City:
Residence:
Apartment / unit
number:
Phone number :
Home : Cell:
Page 2 of 7
Residential Services Application/Referral - Part 1
Community and Social Services
Community Supports
CS-RS 893E
Section 1B - Family composition and living arrangements
Marital status :
Separated Divorced Living common-lawSingle Married Widowed
List all family members living with you including your spouse or common-law partner, dependant children
(17 years or younger) and dependant adults (18 years or older) living with you. If not applicable select Not
applicable :
Spouse/common-law
Not
applicable
Date of birth (DD/MM/YYYY):
First name: Last name:
Dependant children
Not
applicable
Date of birth (DD/MM/YYYY):
First name: Last name:
Date of birth (DD/MM/YYYY):
First name: Last name:
Dependant adults
Not
applicable
Date of birth (DD/MM/YYYY):
First name: Last name:
Date of birth (DD/MM/YYYY):
First name: Last name:
Additional information/comments :
Page 3 of 7
Residential Services Application/Referral - Part 1
Community and Social Services
Community Supports
CS-RS 893E
Section 1C - Assets
List all assets for yourself, spouse or common law-partner, dependant children (17 years or younger) or
dependant adults (18 years or older) living with you. If not applicable, select N/A "not applicable":
Assets : Value / balance : Assets owner :
Bank account / N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Bank account / N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Bank account / N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Investments
(for example
bonds, stocks,
GIC, RRSP,
mutual funds,
RRIF)
N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Vehicle / N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
Pre-paid
funeral /
N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
Property / N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
Life insurance
policy /
N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
Trust
account /
N/A $ Applicant
Spouse/
common-law
Dependant
adult
Child
Other / N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
Please specify :
$
Additional information/comments :
Total asset value :
Page 4 of 7
Residential Services Application/Referral - Part 1
Community and Social Services
Community Supports
CS-RS 893E
Any assets expected in
the future?
Assets : Value / balance : Assets owner :
Yes No
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Additional information/comments :
In the past 12 months,
did you or any family
members living with
you receive any money
from the sale of
something owned (for
example property,
jewellery or vehicle) or
cash in any assets such
as an RRSP or GIC?
Yes No
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Details/comments :
Additional information/comments :
If, yes please provide
details (explain) and
enter amount if known
Page 5 of 7
Residential Services Application/Referral - Part 1
Community and Social Services
Community Supports
CS-RS 893E
Section 1D - Income
Select the sources of income below that are applicable to you, your spouse or common law-partner, dependant
children (17 years or younger) or dependant adults (18 years or older) living with you. If not applicable, select
N/A "not applicable":
Income :
Monthly net
Income :
Income owner :
Ontario
Works /
N/A $ Applicant
Spouse/
common-law
Dependant
adult
Child
Ontario Disability
Support Program
(ODSP) /
N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
OAS/Gains/GIS/
N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
Canada Pension
Plan (CPP) /
N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Quebec Pension
Plan (QPP) /
N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Employment
earnings /
N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
Employment
Insurance /
N/A
$ Applicant
Spouse/
common-law
Dependant
adult
Child
Private pension / N/A $ Applicant
Spouse/
common-law
Dependant
adult
Child
Foreign pension / N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Private
insurance /
N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Investment /
Interest income /
N/A
$
Applicant
Spouse/
common-law
Dependant
adult
Child
Other / N/A
Please specify :
$
Applicant
Spouse/
common-law
Dependant
adult
Child
$
Additional information/comments :
Total net income :
Page 6 of 7
Residential Services Application/Referral - Part 1
Community and Social Services
Community Supports
CS-RS 893E
Section 1E - Consent to release personal information
Signature of applicant :
I, , consent to the
collection and release of applicant information about me as it is collected on this form to an authorized
representative of the City of Ottawa for the sole purpose of determining or verifying my eligibility for the
Residential Services (Domiciliary Hostel) Program.
Witness :
Date :
Personal information is collected under the authority of the Municipal Act, 2001, S.O. 2001, c. 25, sections 8
and 10. Personal information will be used by the City of Ottawa for the purposes of determining eligibility
for and the administration of the Residential Services Program. Questions about this collection and use of
your personal information may be directed to the Administrative Support Clerk at 370 Catherine St., 3rd
Floor, Ottawa, Ontario, K1R 5T5, 613-580-2424 ext. 43511.
(Applicant name)
Page 7 of 7
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Residential Services ApplicationReferral - Part 1 (City of Ottawa)

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Completed 26 January 2022

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