Rent Geared to Income Ontario - PDF

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					         Housing Services Division
         Durham Access to Social Housing
                                           Application for Rent-Geared-to-Income Assistance


Instructions

1.     Read the Application Guide before completing this form.

2.     Please print, and fill out all sections of the application form. You will find
       information at the beginning of each section that explains what is required.


3.     Please have all household members 18 years of age and over read the
       Declaration on the final page of the application and sign the form.


4.     Please have all household members 18 years of age and over read and
       sign the enclosed Consent form.


5.     You may be asked to give proof of any information you have included in your
       application.


6.     After you have completed the application form, return it and the Consent form to
       one of the following Durham Access to Social Housing (DASH) offices:


                              Main Office: Housing Services Division
                                            P.O. Box 623
                                      605 Rossland Road East
                                       Whitby, ON L1N 6A3
                                     Phone:       905-666-6222
                                     Toll free: 1-800-669-2956

                            Access Office: Durham Region Non-Profit
                                     Housing Corporation
                                        28A Albert Street
                                    Oshawa, ON L1H 8S5
                                      Phone: 905-436-6610
      Applications may also be returned to any Region of Durham Social Services
      location including Ontario Works or Employment Supports offices, Regional Child
      Care Centres, Family Services offices, and Region of Durham Long Term Care
      Homes.
7.     If you need any assistance or have any questions about completing the
       application, please contact one of the above DASH offices. For more information
       about social housing, go to www.durham.ca.



                              Please keep your application up to date.

        Tell us immediately if you move or if your telephone number changes.

     If we cannot contact you, your name may be removed from the waiting list and we
                            may be unable to offer you housing.

                                    Keep this page for your records.

                    If this information is required in an alternate format,
                            please contact 1-800-372-1102 ext 2036.
                                  Consent to Disclosure of Information and Documents
                                                                     Social Housing Reform Act, 2000




1.   I consent to the release of information to an authorized representative of the
     Region of Durham and Durham Access to Social Housing (DASH) for the
     purpose of determining past, initial or continuing eligibility for rent-geared-to-
     income (RGI) assistance and/or special needs housing including my placement
     on any applicable waiting lists.

2.   Without restricting the generality of the consent in section 1, I specifically consent
     to the release of information relating to any assets held in any financial institution
     by or on behalf of me, my spouse or same-sex partner, and any dependents in
     my household.

3.   I further consent to an authorized representative of the Region of Durham or any
     of its agents under contract disclosing to any party personal information about
     me, my spouse or same-sex partner, and any dependents included in my
     household for the purpose of determining initial or continuing eligibility for RGI
     assistance and/or special needs housing including my placement on any
     applicable waiting lists.

4.   I further consent to the exchange of information with any agency, Ministry or
     department of the Region of Durham, the Government of Ontario, the
     Government of Canada, the government of any other province or territory, or any
     other party for the purpose of determining initial or continuing eligibility for RGI
     assistance and/or special needs housing including my placement on any
     applicable waiting lists.



      Name of applicant                          Signature                                Date




      Name of spouse/same-sex partner            Signature                                Date




      Names of dependants (18 years and older)   Signature                                Date




                    Notice with Respect to the Collection of Personal Information
                   Municipal Freedom of Information and Protection of Privacy Act
     This information is collected under the legal authority of the Social Housing Reform Act, 2000 for
          the purpose of administering the social housing programs prescribed in this Act and its
      associated Regulations. Questions about this collection should be forwarded to the Director of
        Housing Services, Region of Durham at 605 Rossland Road East, Whitby ON, L1N 6A3 or
                                     905-668-7711 or 1-800-372-1102.
       Housing Services Division
       Durham Access to Social Housing                          Application for Rent-Geared-to-Income Assistance
                                                                                     Part 1: Financial Assessment


Contact Information

Please provide your name and current contact information.
Tell us immediately if you move or if your telephone number changes. If we cannot contact you, your
name may be removed from the waiting list and we may be unable to offer you housing.
Last Name                                                            First Name



Apt/Unit Number      Street Number          Street Name



Town/City                                                            Province                  Postal Code



Home Phone Number                           Work Phone Number                                  Cell Phone Number
(     )                                     (         )                                        (           )

Email addresses:



Alternate Person to Contact:                              Phone number (where we can leave a message):

                                                          (          )


Household Information

Please provide information about all adults and children – including yourself – who will live with you.

                                                                 Relation-           Date of Birth         Male/    Social Insurance
       Last Name                         First Name
                                                                   ship              Day/Month/Year       Female        Number

                                                                     Self




Do all of the people listed currently live with you?                                Yes             No
If no, please provide the name of the person, the date this person will start living with you, and the reason they
are not living with you now:




Is any member of your household expecting a baby?                                         Yes                No

If yes, please provide expected due date:             _______________________
                                                              (Day / Month / Year)
                                                          Application for Rent-Geared-to-Income Assistance (Part 1)




Status in Canada

Were all the people in your household born in Canada?                                 Yes          No
Please provide information for all people born outside of Canada.

                                      Date moved to            Current status in                  Is there a
                                                                                                                      Date sponsorship
              Name                                                                               sponsorship
                                                                                                                      agreement ends
                                         Canada                    Canada                    agreement in place?


                                                                                              Yes  No

                                                                                              Yes  No

                                                                                              Yes  No

                                                                                              Yes  No


Rental History

Current landlord’s name:                                                 Landlord telephone number:



Do you pay subsidized rent where you live now?                                Yes                      No   
 Address where you previously lived                                                                  Amount             Was your rent
                                            Name of landlord              Move out date                                 subsidized?
    and paid rent / owned home                                                                      owing ($)




Application for Special Priority Status

Complete this section only if you are applying for priority on the waiting list because someone that you live
with is abusing you.
You will also need to complete the Special Priority Application package which you can get at any DASH
office and submit it with this application.

Name of person requesting priority:          I am applying for special priority due to abuse by:


                                              (Name of abusive person)                                      (Relationship)


       I am currently living with this person and intend to permanently live apart from them.

       I have not lived with this person since: ___________________________________________________.
                                                                             (Date you stopped living together)


Please provide a safe mailing address where you can be contacted:

       Same as address and telephone numbers given in Section 1 OR
Apt/Unit Number       Street Number     Street Name


Town/City                               Postal Code                      Safe daytime phone number for contact:
                                                                         (         )
                                                       Application for Rent-Geared-to-Income Assistance (Part 1)



Income Information
List all money you and the people who will be living with you receive from all sources. This can include, but is
not limited to, income sources such as:

  Old Age Security/Guaranteed            Employment (full time, part time,       Ontario Works (OW)
  Income Supplement (OAS/GIS)            casual)
                                                                                 Ontario Disability Support Plan
  Guaranteed Annual Income               Employment Insurance (EI)               (ODSP)
  Supplement (GAINS)
                                         Workplace Safety Insurance Board        Canada Pension Plan (CPP)
  Retirement Income Fund (RIF)           (WSIB)
                                                                                 Investment Income
  payments
                                         Child support payments                  (e.g. interest / dividends)
  Life Income Fund (LIF) payments
                                         Alimony or spousal support
  Other pensions (e.g. company,          payments
  private, foreign, military)

                                                                                          Gross monthly income
     Name of person receiving income                      Income source
                                                                                          (before income tax and other
                                                                                                   deductions)




Have you applied for any other types of income?               Yes               No


Date of application: ___________________________           Type of income: ______________________________


Asset Information

List all assets owned by you and all other people who will be living with you. Assets are things that you own.
Some assets give you income and others do not, but all assets must be declared. Assets include, but are not
limited to, things such as:

  Bank accounts                        Registered Retirement Savings             Registered Education Plans
  Cash (over $1000)                    Plans (RRSP)                              (RESP)
  Term Deposits                        Stocks / Shares                           Collections or valuables
  Guaranteed Investment                Mutual Funds                              Real estate
  Certificates (GIC)
                                       Life Insurance (cash surrender
  Saving Bonds                         value)
                                                 Details of Asset
 Name of person who owns
                                     (type, account number, name of financial          Value / Account Balance ($)
        the asset
                                                    institution)
                                                                         Application for Rent-Geared-to-Income Assistance (Part 1)



Asset Information (continued)

Does any household member on this application own property
(e.g. house, cottage, farm, land, mobile home, trailer, etc.)?                                               Yes                No

If Yes, please give the following information:
Type of Property                            Location                                                                  Assessed value ($)

                                                                                                                      Mortgage owing($)

Have you transferred any assets to another person within the last three years?                                               Yes              No
If yes, please provide details.




Self-employment / Business Information

Are you self-employed or do you own your own business?                                                    Yes               No
If yes, please provide name of business, annual income and estimated value of business assets:




Declaration

 1. I declare that all information given for this application is true to the best of my knowledge and that I have
    not withheld or left out any required information.

 2. I declare that no member of my household is currently under a removal order to leave Canada.

 3. I agree to inform the Commissioner of Social Services for the Regional Municipality of Durham, or his or
    her designate, of any changes in my income, assets, contact information or household composition.

 4. I understand that the information given for this application may be used for the purpose of making
    decisions or verifying eligibility for assistance under the Social Housing Reform Act, 2000, the Ontario
    Disability Support Program Act, 1997, the Ontario Works Act, 1997, or the Day Nurseries Act.

 5. I understand that if something on this form is incorrect or not true, I may be ineligible for rent-geared-to-
    income assistance and may be prohibited from re-applying for a minimum period of two years.

 Name (please print)                                             Signature                                                              Date
 Applicant


 Spouse


 Dependants (18 years of age and older)




                                            Notice with Respect to the Collection of Personal Information
                                             Municipal Freedom of Information and Protection of Privacy Act

     This information is collected under the legal authority of the Social Housing Reform Act, 2000 for the purpose of administering the social housing
                                               programs prescribed in this Act and its associated Regulations.
                       Questions about this collection should be forwarded to the Director of Housing Services, Region of Durham at
                                    605 Rossland Road East, Whitby ON, L1N 6A3 or 905-668-7711 or 1-800-372-1102.
                                                         Application for Rent-Geared-to-Income Assistance
                                                                                  Part 2: Building Choices


Instructions:


In this Part of the application you will find three lists of housing providers that offer rent-geared-to-income
or subsidized housing. Utilities are included in the housing charge for the unit, unless indicated
otherwise. Please review these lists and mark an "X" next to the building(s) where you would like to live.
These are the only places where you will be offered housing.

Please choose carefully as you can receive only three offers before your name is removed from the
waiting list for all locations. You can change your selections at any time by contacting any DASH office.

If you want more information - including photos - about any of the buildings listed below you can contact
any DASH office or visit www.durham.ca.


Size of Unit:                                                      Modified Units:

There are rules about the size of unit (number of                  Do you require a modified unit (e.g.
bedrooms) that you can move into if your rent is                   wheelchair accessible unit)?
subsidized. The largest unit size allows one
bedroom per person; spouses are expected to                                    Yes            No
share.
                                                                   If Yes, details of the medical need for the
What size unit do you want to move into?                           modified unit must be provided by a health
(check all that apply)                                             care professional.

      Bachelor (Oshawa locations only)                             When you see the symbol        below, this
                                                                   means that this housing provider has some
      One bedroom
                                                                   modified units in this bedroom size in addition
      Two bedroom                                                  to their non-modified units.

      Three bedroom                                                Parking:
      Four bedroom                                                 Do you require parking?
      Five bedroom (Oshawa locations only)                                  Yes              No


Housing Providers with units that accommodate Singles, Couples and Families

Anyone can apply to these housing providers.
                                                                             Size of unit /
                                                            Bldg          number of bedrooms
   Building Name                  Address                                                                 Notes
                                                            Type
                                                                      B    1     2   3   4     5

   Ajax

   I want to select all units in AJAX.

   Duffins Creek Landing          1 Marsh Lane               TH                                    Utilities not included


   Monarch Mews                   40 Kitney Dr.              TH                                    Utilities not included

                                                                                                   Utilities not included
   Post Hill                      132 Kingston Rd. W.      APT & TH
                                                                                                           Elevator

   River Breeze                   1 Richards Lane            TH                                    Utilities not included


   Unity Village                  120 Old Kingston Rd.       APT                                         Elevator
                                                          Application for Rent-Geared-to-Income Assistance (Part 2)



                                                           Bldg          Number of bedrooms
Building Name                 Address                                                                    Notes
                                                           Type      B     1   2   3   4      5

Brock

I want to select all units in BROCK.

Old Schoolhouse Apartments    28 Queen St., Cannington      APT


St. Andrew's Place            112 River St., Sunderland     APT



Clarington

I want to select all units in CLARINGTON.

                              41 Freeland Ave.,
Bowmanville Heights                                       APT & TH                                Utilities not included
                              Bowmanville
                              114 Concession St. E.,       Stacked
Campbell Court                                               APT
                                                                                                  Utilities not included
                              Bowmanville
                              94 Concession St. E.,
Mearns Meadows                                               TH                                   Utilities not included
                              Bowmanville


North Oshawa (north of Hwy 401)

I want to select all units in NORTH OSHAWA.

                                                                                                  Utilities included for
Beatrice Woods                570 & 580 Beatrice St. E.   APT & TH
                                                                                                  apartment units only

Chris Mason Hall              173 Westmount St.             APT                                   Utilities not included


Cy Elsey Building             28 Albert St.                 APT                                         Elevator

Gateway Chambers              375 Buena Vista               APT

Gateway Terrace               120 Colborne St. W.            TH

                                                                                                  Utilities not included.
Linden/Poplar                 Linden St. & Poplar St.      4- PLEX                                Tenant must provide
                                                                                                  own fridge and stove
                                                                                                  Tenant must provide
Lomond                        Lomond St.                    SEMI
                                                                                                  own fridge and stove
                                                                                                  Tenant must provide
Nevis /Christine/Normandy     Nevis St.                     SEMI
                                                                                                  own fridge and stove
                                                                                                  Utilities not included
New Hope Dwellings            139 Mary St. N.               APT
                                                                                                          Elevator

Ormond Place                  240 Ormond Dr.                 TH                                   Utilities not included


Owen D. Friend                485 /501 Normandy             APT

                                                                                                  Utilities included for
Wilson Village                765/767/769 Wilson Rd. N. APT & TH
                                                                                                  apartment units only

South Oshawa (south of Hwy 401)

I want to select all units in SOUTH OSHAWA.

                                                                                                  Tenant must provide
Cedar/Carleton/Wasaga         Carleton Court                SEMI
                                                                                                  own fridge and stove

Conant Place                  1050 Simcoe St. S.             TH                                   Utilities not included


Interfaith Homes              231 Bloor St. W.              APT                                         Elevator
                                                              Application for Rent-Geared-to-Income Assistance (Part 2)



                                                                Bldg         Number of bedrooms
   Building Name                  Address                                                                        Notes
                                                                Type     B     1   2   3     4      5

   South Oshawa (continued)

                                                                                                         Tenant must provide
   Lakeview                       229 Lakeview Park Dr.          TH
                                                                                                         own fridge and stove
                                                                                                         Tenant must provide
   Malaga                         Malaga Rd.                     TH
                                                                                                         own fridge and stove


   Pickering

   I want to select all units in PICKERING.

   Highbush Village               1840 Westcreek Dr.             TH                                      Utilities not included


   Orchard Valley Court           1580 Kingston Rd.              TH                                      Utilities not included

                                                                                                         Utilities not included
   Sarah McDonald's Place         1467 Whites Rd.                APT
                                                                                                                 Elevator


   Uxbridge

   Reach Gardens                  57 Enzo Cres.               APT & TH                                   Utilities not included



   Whitby

   I want to select all units in WHITBY.

   Cormack Station                250 Hickory St. S.             APT                                            Elevator


   Dryden Heights                 90 Waller St.                  APT                                            Elevator


   Garrard Heights                123 Eric Clarke Dr.            TH                                      Utilities not included


   Harvest Place                  106 Rossland Rd. W.            TH                                      Utilities not included


   Marigold Court                 3438 Garrard Rd.               TH                                      Utilities not included

                                                                                                              Singles only
   Perry Terrace                  220 Perry St.                  APT
                                                                                                                Elevator

                                                                                                           Utilities and elevator
   Prisma Non-Profit Homes        116-120 Waller St.          APT & TH
                                                                                                        included for apt units only


   Woodfarm Manor                 1525 Nichol Ave.               APT                                            Elevator




Rent Supplement Units:

From time to time, units become available in buildings owned by private landlords. These units can be
subsidized by the Region of Durham under the Rent Supplement Program. As the locations of these
units can change, waiting lists are kept according to the city or town only.

If you are interested in being offered a rent supplement unit by a private landlord, please indicate below
the city or town you would like to live in. You can check more than one box.

            North Oshawa                          South Oshawa
            (north of Hwy 401)                    (south of Hwy 401)
                                                                                           Whitby
                                                       Application for Rent-Geared-to-Income Assistance (Part 2)



CO-OPERATIVE (CO-OP) HOUSING PROVIDERS

People who live in Co-operative (Co-op) housing are members of a community. Members contribute
their time to the management and day-to-day operation of the co-op by volunteering with various
member committees.

In order to live in a Co-op you must first be approved for membership by the co-op. Anyone can apply
for membership. You may be asked to attend an information session before being considered for
membership.

For more information about Co-operative Housing you can contact any of the co-operative housing
providers listed in the section below or visit www.chfc.ca.

                                                        Bldg          Number of bedrooms
   Building Name                Address                                                                 Notes
                                                        Type      B     1   2   3   4      5

   Clarington

                                59 Jackman Rd.,                                                 Utilities included for
   Bowmanville Valley Co-op                            APT & TH
                                Bowmanville                                                     apartment units only


   Oshawa

   I want to select all CO-OP units in OSHAWA.

   Consideration Co-op          22 Beatrice St. E.       APT                                           Elevator


   Harmony-King Co-op           20 Harmony Rd. N.        APT                                           Elevator


   Maple Glen Co-op             777 Wilson Rd. N.         TH                                    Utilities not included

                                                                                                  Utilities and elevator
   Northview Meadow Co-op       1252 Pentland St.      APT & TH
                                                                                               included for apt units only

                                                                                                Utilities included for
   Willow Park Co-op            610 Beatrice St. E.    APT & TH
                                                                                                apartment units only


   Pickering

   I want to select all CO-OP units in PICKERING.

   Duffins Creek Co-op          1555 Finch Ave.           TH                                    Utilities not included

                                                                                                Utilities not included
   Rougemount Co-op             400 Kingston Rd.         APT
                                                                                                        Elevator

   William Peak Co-op           1990 Whites Rd.           TH                                    Utilities not included



   Scugog

                                10 Borelia Cres.,
   Borelia Co-op                                       APT & TH                                 Utilities not included
                                Port Perry


   Whitby

   I want to select all CO-OP units in WHITBY.

   Marigold Co-op               121 Ash St.              APT                                           Elevator


   Otter Creek Co-op            830-855 McQuay Blvd.      TH                                    Utilities not included
                                                            Application for Rent-Geared-to-Income Assistance (Part 2)



SENIORS HOUSING PROVIDERS

You must be at least 60 years of age to apply to these housing providers.

                                                             Bldg         Number of bedrooms
   Building Name                Address                                                                   Notes
                                                             Type     B     1   2   3    4     5

   Ajax

   I want to select all SENIORS units in AJAX.

   Ashley Manor                 40 Kitney Dr.                 APT                                        Elevator

   Duffins Creek Landing        1 Marsh Lane                  APT                                        Elevator

   Harwood Manor                655 Harwood Ave. S.           APT                                        Elevator

                                                                                                   Utilities not included
   Post Hill                    132 Kingston Rd. W.           APT
                                                                                                           Elevator

   Unity Village                120 Old Kingston Rd.          APT                                        Elevator

   Westwood Manor               960 Westney Rd. S.            APT                                        Elevator


   Brock

   I want to select all SENIORS units in BROCK.

                                75 Nine Mile Rd.,
   Gillespie Gardens                                          APT                                        Elevator
                                Beaverton
                                36 Church St.,
   Maple Glen Apartments                                      APT                                        Elevator
                                Sunderland
                                103 Cameron St. W.,
   Spruce Haven                                               APT                                        Elevator
                                Cannington
                                342 Main St.,
   Wayside Apartments                                         APT                                        Elevator
                                Beaverton


   Clarington

   I want to select all SENIORS units in CLARINGTON.

   Durham County Srs Lodge      200 Station St. W., Orono      TH

                                108 Liberty St. N.,                                                Utilities not included
   Forestree Place                                            APT
                                Bowmanville                                                                Elevator
                                2-4 Nelson St.,
   Nelson                                                     APT                                        Elevator
                                Bowmanville
                                165 King St. E.,
   Newcastle Lodge                                            APT                                        Elevator
                                Newcastle


   Oshawa

   I want to select all SENIORS units in OSHAWA.

   Beatrice Terrace             385 Beatrice St. E.           APT                                        Elevator

   Dean Heights                 439 Dean Ave.                 APT                                        Elevator

   Faith Place                  44 William St. W.             APT                                        Elevator

   Gateway Terrace              155 Kaiser Cres.              APT                                        Elevator

   King Charles Court           155 King St. E.               APT                                        Elevator
                                                              Application for Rent-Geared-to-Income Assistance (Part 2)



                                                               Bldg         Number of bedrooms
 Building Name                  Address                                                                     Notes
                                                               Type     B     1   2   3    4     5

 Oshawa (SENIORS units continued)

 Kingsway Pioneer Homes         1250 King St. E.                APT                                        Elevator

 Legion Manor                   470 Albert St. S.               APT                                        Elevator

                                                                                                     Utilities not included
 New Hope Dwellings             139 Mary St. N.                 APT
                                                                                                             Elevator

 Normandy Hall                  460 Normandy St.                APT                                        Elevator

 Parkview Place                 25 John St. W.                  APT                                        Elevator

 Sunrise Place Co-op            130 Centre St. S.               APT                                        Elevator

 Sunrise Seniors                75 John St. W.                  APT                                        Elevator



 Pickering

 I want to select all SENIORS units in PICKERING.

 Fairport Lodge                 1330 Foxglove Ave.              APT                                        Elevator

 St. Martin's Centre            1201 St. Martin's Drive         APT


 Villa Valeau                   1910 Faylee Cres.               APT                                        Elevator

 William Peak Co-op             1990 Whites Rd.                 APT                                        Elevator



 Scugog

 I want to select all SENIORS units in SCUGOG.

 Immaculate Conception          61 Ash St., Port Perry          APT                                        Elevator

 Kellett Manor                  327 Kellett St., Port Perry     APT                                        Elevator

 Spruce Lawn Apartments         385 Rosa St., Port Perry        APT                                        Elevator



 Uxbridge

 Brookside Apartments           20 Perry St.                    APT                                        Elevator



 Whitby

 I want to select all SENIORS units in WHITBY.

 Bowling Green Towers           850 Green St.                   APT                                        Elevator

 Centre                         409 Centre St. S.               APT                                        Elevator

 Durham Christian Homes         100 Glen Hill Dr. S.            APT                                        Elevator

 Harvest Place                  106 Rossland Rd. W.             APT                                        Elevator

 Perry Terrace                  220 Perry St.                   APT                                        Elevator

 Windsor Place                  315 Colborne St. W.             APT                                        Elevator




               You should tell us immediately if you move or if your telephone number changes.
If we cannot contact you, your name may be removed from the waiting list and we may be unable to offer you housing.

				
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Description: Rent Geared to Income Ontario document sample