Ontario Works Community Start Up and Maintenance Benefit by leader6

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									                       Community Start Up and Maintenance Benefit
                      Request to Establish a New Principal Residence

Name: ______________________________________________ Team #: ____________________

Date of Birth: _____________________________            Member ID: ___________________________

   IMPORTANT PLEASE READ ALL OF THE FOLLOWING INFORMATION 
Community Start Up and Maintenance Benefits (CSUMB) provide financial assistance to Ontario Works
recipients who are dislocated and are setting up independent, permanent residences.
You may be eligible for CSUMB if you have not received a CSUMB in the past 24 months and:
   1. you are establishing a permanent and/or independent residence in the community upon
      discharge from hospital, jail, mission, shelter, or residence where your basic needs were provided
   2. staying in your current residence is harmful to your health and well being
   3. you are forced to vacate your current residence due to circumstances beyond your control, such
      as:
          - notice to vacate premises
          - residence is uninhabitable (safety/security)
          - landlord has sold the building and has terminated your tenancy
   4. you must move to participate in a training or employment opportunity
   5. you have obtained more affordable housing
Reason for Request: please enter number from reasons above ___ and/or, provide comments below:
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
_______________________________________________________________________
Verification required to support your request for CSUMB:
    written confirmation of the date of discharge from hospital, jail, mission, shelter, or residence
        where your basic needs were provided
    letter from licensed health care practitioner stating why current residence is harmful to your
        health
    copy of the notice to evict, letter from building or health inspector, or copy of notice to terminate
        tenancy
    written verification of training or employment opportunity requiring a move
The amount of the CSUMB payable is up to a maximum of $1500 for recipients with dependent children
on the benefit unit, or up to a maximum of $799 for all other recipients, in a 24-month period.
The following verification is required to verify costs:
    new lease/rental agreement stating that last months rent is required
    written confirmation from utility company(s) of amount of security deposit required
    written estimate from moving company for mover’s fees or truck rental
    estimate(s) for essential household items – receipts must be provided after items have been
       purchased

PLEASE NOTE: If CSUMB is used for purposes other than what it was intended for,
or if receipts are not provided, an overpayment charge may be applied.



I have read the information above:        ______________________________________________
                                                                Participant’s Signature
Items that you are requesting help with:


      ITEM                                                                              AMOUNT REQUESTED

       Moving Expenses (estimate from moving company required)                            $_______________

       Last Months Rent (verification from Landlord required)                             $_______________

       Utility Deposits (verification from utility company/companies required)            $_______________

       Furniture and Household Items                                                      $_______________
      NOTE: following the purchase of furniture and household Items (see appendix A).
      Receipts must be provided. Please list items and the approximate cost:
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________


       Other                                                                                $______________
      NOTE: following the purchase of Items receipts must be provided
      Please list items and cost: ________________________________________          $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________
      ______________________________________________________________                 $________


                                                           Total Amount Requested: $______________
    If last months rent is approved, it will be paid directly to the Landlord. Please submit a completed
     Landlord Letter with your Community Start Up and Maintenance Request. The Landlord letter
     must include the Landlord’s name, address, postal code, and telephone number.
    If security deposits are approved, the cheques will be sent directly to the Utility Company.
    If approved for moving costs, furniture, household or other items, please check delivery option
     preferred for cheque:
       Mailed                Picked-Up in the Clinton Office                  Delivered to Shelter


Participant’s Signature:     _____________________________________                        Date: __________

                                                                                                  Print Form
Appendix A

Helpful list of items to consider when starting up a new residence:

      Kitchen Supplies                                 Linen Supplies
      Potato peeler                                    Sheets
      Can opener                                       Pillow cases
      Paring knife                                     Pillows
      Bread knife                                      Blankets / quilts
      Ladle                                            Hand towels
      Rubber spatula                                   Bath towels
      Lifter spatula                                   Face cloths
      Wooden spoons                                    Bath mat
      16 piece cutlery and tray                        Shower curtain
      20 piece dish set
      Juice container                                  Furniture
      Salt and pepper shaker                           Table lamps
      Canister set                                     Coffee Table
      Cream and sugar                                  End table
      Serving bowl                                     Couch
      Mixing bowls                                     Chair
      Cake pan                                         Beds
      Cookie sheet                                     Dresser
      Muffin tin                                       Kitchen table / chairs
      Meat loaf / bread tin
      Frying pan                                       Cleaning Supplies
      1 quart pot                                      Mop / pail
      2 quart pot                                      Broom
      Dutch oven / roaster                             Dust pan
      Casserole dish                                   Vacuum / electric broom
      Measuring cup                                    Sponges
      Measuring spoons
      Toaster                                          Miscellaneous
      Kettle                                           Clock
      Tea / coffee pot                                 Scissors
      Mixer                                            Iron
      Tea towels                                       Ironing board
      Dish cloths                                      Laundry hamper
      Cutting board                                    Waste basket
      Oven mitts                                       Garbage pail
      Pot holder                                       Clothes pins
      Dish rack / tray                                 Sewing kit
                                                       Curtains

								
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