Microsoft Word - 3000 - Application for RGI Housing.PDF (Revised 2017-06-01).docx

Gender

Status in

efugee claimant

Calls to offer h

of 8:30AM to 4:30PM, Monday to Friday

e number

nal calls?

Yes

Mailing add

time telephone number

Do you ne

Yes

Did someo st the applica appli

Yes - please provide their information:

Mr. Mrs. Ms.

Male

Female

Date of birth

(YYYY MM DD)

Social Insurance Number

arital status

Single Married

Common law

Canada

Canadian citizen Landed immigrant

Refugee or R

ousing are normally made during the day. Please provide us w

Daytime telephone number Home telephone number (if different) Cellular telephon

Work telephone number / including extension

Can you take perso

ress, if different than above.

Apartment number Street address

City Province

Alternate contact name (where we can leave a message) Alternate's day

What is your primary language?

ed an interpreter?

ne assi nt with this cation?

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 1 of 10

•

Please print clearly.

•

All sections must be completed in full.

•

If your application is not completed in full, it may be returned to you unprocessed.

SECTION 1 - Your information

Primary applicant

Include copies of Canadian birth certificates, Canadian passport, landed immigrant, permanent resident card or refugee

claimant documents for ALL listed on the application.

Last name First name and middle initial

Maiden name (if applicable)

Divorced

Widowed

Other

Applied for permanent residence

Apartment number Current address

Cit

Province Postal code

ith a daytime number where you can be reached during the hours

E-mail address

What hours do you work?

Postal code

Alternate's relationship to applicant

Full name:

Phone number:

Relationship:

May we contact them?

No Yes

Permission to send mail or discuss your application?

No Yes

Form no. 3000 (rev.2017-05)

www.london.ca

bedroom

of unit you have selected.

bedroom

the people listed on this application be permanently living wit

Yes (provide verification); date expe

Are any members of the household under a deportation or departure or

Have you or anyone in your household been convicted of an offence

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 2 of 10

SECTION 2 - Who will live in the Rent Geared-to Income (RGI) unit?

List the name of all persons, starting with the Primary Applicant, who will be living in the RGI

Unit. Only the persons listed as members of this household can live in the subsidized unit.

You must attach proof of legal status in Canada for all listed.

Status in Canada

Social Insurance Number

Canadian Citizen

Landed

Immigrant

Refugee or Refugee

Claimant

Applied

for

Permanent

Residence

Last Name First Name

Relationship to

Primary Applicant

Gender

Date of Birth

YYYY MM DD

Bachelor

1 bedroom 2

verify if you are eligible for the size

3 bedroom 4 bedroom 5

h you? Yes No

cted

(YYYY MM DD)

der?

Yes

I/we wish to apply for the following size of unit:

The number of bedrooms you are eligible for is determined by the

occupancy standards that apply to your household size. HAC will

Will all

If no, please explain:

Is a baby expected?

related to rent geared-to-income housing within the last two years?

Do all family members currently live with you?

ou share custod

of the children listed in this a

lication?

Yes

If yes, please provide custody documentation.

Yes

Do you own, or are you a co-owner of, the home you are currently living in?

If yes, please complete and sign a Divestment form.

Contact HAC or visit our website to receive a copy of the form.

What is the estimated value?

Yes

Do you or anyone on this application own property in Canada or

any other country?

If yes, please complete and sign a Divestment form.

Contact HAC or visit our website to receive a copy of the form.

What is the estimated value?

Form no. 3000 (rev.2017-05)

www.london.ca

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 3 of 10

SECTION 3 - Current and previous residences

Please provide information regarding your current landlord

Landlord's full name Landlord's telephone number

Landlord's apartment number Landlord's street address

Landlord's city Landlord's province Landlord's postal code

Date you moved into your current residence

How much rent do you pay?

May we contact your landlord?

Yes

Previous addresses -- please list the addresses where you have lived for the past 5 years (prior to your current

Apartment number Street address Date moved IN

City Province Postal code Date moved OUT

Landlord's full name Landlord's telephone number

Landlord's apartment no. Landlord's address

Landlord's city Landlord's province Landlord's postal code

Was your housing subsidized? Yes No Are there arrears/rent owing on this residence? Yes No

Apartment number Street address Date moved IN

City Province Postal code Date moved OUT

Landlord's full name Landlord's telephone number

Landlord's apartment number Landlord's address

Landlord's city Landlord's province Landlord's postal code

Was your housing subsidized? Yes No Are there arrears/rent owing on this residence? Yes No

Apartment number Street address Date moved IN

City Province Postal code Date moved OUT

Landlord's full name Landlord's telephone number

Landlord's apartment number Landlord's address

Landlord's city Landlord's province Landlord's postal code

Was your housing subsidized? Yes No Are there arrears/rent owing on this residence? Yes No

Form no. 3000 (rev.2017-05)

www.london.ca

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 4 of 10

SECTION 3 - Current and previous residences

(continued) Current or previous social housing

Have you or anyone listed in your application ever lived in rent geared-to-income (subsidized) housing?

No - skip to "Accommodation requirements" Yes - complete the following.

Name of person(s) who lived in social housing Name of housing provider

Apartment number Street address where you lived

City Province Postal code

Date moved in Date moved out

Reason for moving out

Does this person owe rental arrears to the above or to any other social housing provider? No

Yes

If yes, what is the amount owing?

Have you entered into a repayment schedule?

Yes

es,

lease attach a co

of the re

ment schedule.

Accommodation requirements

There are a number of social housing units in London that have been modified to accommodate people with physical disabilities.

Do you or anyone who plans to live with you need a wheelchair accessible building?

Name of family member:

If yes, we will mail a medical form to you that you must have your doctor complete.

Yes

Do you or anyone who plans to live with you need a modified unit for a physical disability?

Name of family member:

Yes

Please describe the

specific requirements:

Do you or anyone who plans to live with you need support services in order to live independently?

If yes, we will mail a medical form to you that you must have your doctor complete.

Name of family member:

Yes

Do you/they have support services presently in place?

Yes

What type of service

(Supportive Housing) is

required?

Form no. 3000 (rev.2017-05)

www.london.ca

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 5 of 10

SECTION 4 - Income information

What income do you and the other people who live with you receive each month?

Income means all money you receive, from all sources. Here are some examples of possible places from which you

receive income:

Employment Self-Employment

 Full-time work  Seasonal or vacation pay  Sickness pay  Tutoring

 Part-time work  Yearly bonuses  Tips or gratuities  Child care

 Irregular work  Cost of living bonuses  Commissions  Driving a taxi

 Casual work  Long term disability  Overtime pay  Teaching music

 Seasonal work  Short term disability  Farm income

 Odd jobs  Shift bonuses  Any other business income

Pensions, Allowances and Other Income

 Ontario Works

 Employment Insurance

 Canada Manpower Retraining Allowance

 Ontario Disability Support Plan

 Training allowances

 One time lump sum payments

 Canada Pension Plan

 Company pensions

(e.g., inheritances, court and out-of-court

 Old Age Security

 Annuities

settlements)

 Quebec Pension Plan

 Public service pensions

 Mortgage income

 Alimony/support payments

 Workers Compensation payments

 OSAP grants

 War Veteran's Allowances

 Sponsorship payments

Documentation to verify your income must be attached to your application. Please note: You may become ineligible for rent-geared-to-

income assistance if you do not make reasonable effort to pursue income you may be eligible for under Ontario Works, Support ordered

under the Divorce Act (Canada), Family Law Act, or Interjurisdictional Support Orders Act, 2002, Employment Insurance benefits, Senior's

pensions or benefits from the Government of Canada or Government of Ontario or Immigration support or maintenance.

List all money you and all persons who will be living with you receive from all sources.

Name of Household Member

Income Source

(refer to examples above)

Gross Income per Month

(before deductions)

Total monthly income: $

Form no. 3000 (rev.2017-05)

www.london.ca

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 6 of 10

SECTION 5 - Assessment information

Assets are valuable things that you own. There are some assets that give you income and there are others that do not. All types

of assets must be declared. Here are some examples of both kinds of assets:

Assets that give you income: Assets that do not give you income:

 Real estate which you rent to someone (example: business, farmland,

 Life insurance (with a cash surrender value)

cottage or mobile home)  Real estate that does not give you income

 A licence which gives you income (example: taxi licence)

(example: your own home, summer cottage,

 Business assets

farmland, commercial or vacant land)

 All investments, including bank accounts, Guaranteed Investment

Certificates, stocks or shares, bonds, debentures, mortgages, loans,

notes or term deposits, mutual funds, Canada Savings Bonds, etc.

List all assets owned by you and all persons who will be living with you. You do not need to include personal vehicles or

household furnishings.

Name of Household Member

Type of Asset

(refer to examples above)

Value

Total value of assets: $

Form no. 3000 (rev.2017-05)

www.london.ca

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 7 of 10

SECTION 6 - Application for Special Priority Status (Domestic abuse)

The special priority status is reserved for applicants who have been abused by another individual residing in their household.

Special priority assists applicants who need rent geared-to-income (RGI) housing to permanently separate from the abusing

individual.

Applicants with special priority status go to the top of the waiting list for rent geared-to-income housing. Special priority is given

to people who need affordable housing to leave an abusive relationship. In order for your request for special priority status to be

considered, you must first meet the eligibility criteria for rent geared-to-income (RGI) assistance.

To apply for special priority status you must complete the “Request for Special Priority” and “Verification of Abuse” forms. To

access these forms go to www.london.ca/housing and click “Finding Social and Affordable Housing/Applying for Social

Housing” or call 519-661-0861 to have one mail to you or drop by our office to pick one up at 355 Wellington Street, Suite 248.

As part of applying for special priority you will need to have a qualified professional complete the “Verification of Abuse” form

and provide a letter describing the indicators of abuse.

Are you living with someone who threatens your safety or the safety of anyone else listed on this application?

Would you like us to mail the “Request for Special Priority” and “Verification of Abuse” forms to the following

safe

mailing address?

Yes

Apartment number

Street address

Cit

Province

Postal code

SECTION 7 - Application for Urgent Status

In order for a household to be considered by the Service Manager to have Urgent status it must fall within the High Income Need

category and a helping professional has identified that a member of the household is at serious risk due to one or more of the

following criteria: Person(s) living in substandard housing which has been condemned by the municipality; Person(s) whose

accommodation has recently been destroyed by fire or natural disaster and who have no place to live; Person(s) awaiting release

from hospital or other medical facility, who cannot return to their former place or residence and have no place to live; Households

whose child(ren) would be returned to their custody by a child protection agency when adequate housing is provided and lack of

housing is the only condition of custody left outstanding; Person(s) with serious medical, health and or social needs which would

result in severe hardship or personal risk to the applicant if required to wait a prolonged period of time to access housing;

Person(s) whose personal safety is significantly at risk (other than someone in the Special Priority category); Households without

permanent residence; Households who use the emergency shelter system; Families separated due to lack of affordable housing.

Below you will find a checkbox for “Request for Urgent Homeless Status”, “Request for Urgent Medical Status”, and “Request for

Urgent Social Status.” Check the box of the Urgent status you would like to apply for and the appropriate form will be forwarded to

your mailing address indicated in your application OR to access these forms go to www.london.ca/housing and click “Finding

Social and Affordable Housing/Applying for Social Housing” or call 519-661-0861 to have one mail out to you or drop by our office

to pick one up at 355 Wellington Street, Suite 248 indicating which Urgent status you are applying for. Please note that you could

only be approved for one status.

Urgent Homeless Status Urgent Medical Status Urgent Social Status

SECTION 8 - Location preferences

Please refer to the attached Building Selection Sheet (City form number 3001) to indicate which zone(s)/building(s) you prefer to

live in. This must be included when you send in your application form.

Form no. 3000 (rev.2017-05)

www.london.ca

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 8 of 10

SECTION 9 - Release and consent

Personal information contained in this form or in any attachments to it is collected by the Housing Access Centre for the City of London &

County of Middlesex and/or the Housing provider, pursuant to the Freedom of Information and Protection of Privacy Act or the Municipal

Freedom of Information and Protection of Privacy Act and will be used only as set out in this form. The information will be used to determine

current/on-going eligibility to rent-geared-to-income assistance, as well as for statistical reporting. The information provided may be cross-

referenced with other municipal data pertaining to the household.

This is your legal agreement with us to consent to the release of your personal information.

I understand that the Housing Access Centre for the City of London & County of Middlesex as Service Manager and any

Housing Provider listed in my application for rent geared-to-income ("RGI") assistance are permitted under the Housing

Services Act, 2011 (the “Act”) to collect personal information about me so long as they comply with the standards for

collecting, using, disclosing and safeguarding information as set out in the Act.

I understand and agree to release any personal information and required documents to either the Housing Access Centre for

the City of London & County of Middlesex and/or the Housing Provider for the purpose of processing my application for RGI

assistance which may include determining:

(a)

my initial and ongoing eligibility for RGI assistance;

(b)

the size and type of unit that I may be eligible for;

(c)

the amount of geared-to-income rent I will be required to pay.

Any personal information collected by the Housing Access Centre for the City of London & County of Middlesex and/or the

Housing Provider about me for the above mentioned purpose will be hereafter referred to as “my personal information”.

I agree to release to the Housing Access Centre for the City of London & County of Middlesex and/or the Housing Provider

information 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 dependents or children temporarily in my care, alone or jointly with any other person in any financial

institution, in order to verify my initial or ongoing eligibility for RGI assistance.

For the purpose set out in paragraph 2, I allow the Housing Access Centre for the City of London & County of Middlesex and/

or the Housing Provider to obtain any credit information about me from any credit agency or any other source.

I allow the Housing Access Centre for the City of London & County of Middlesex and/or the Housing Provider to share my

personal information, without further notice to me, with the Ministry of Municipal Affairs and Housing, the Social Housing

Services Corporation, other municipal service managers or district social services administration boards or lead agencies as

defined under the Act, and each person or organization providing services by contract to any of them, if it is needed to make

decisions or verify my eligibility for assistance under the Act, the Ontario Works Act, 1997,the Ontario Disability Support

Program Act, 1997 or the Day Nurseries Act.

I understand that any of my personal information given by the Housing Access Centre for the City of London & County of

Middlesex and/or the Housing Provider to a government or body mentioned above in paragraph 5 is confidential and will only

be given in accordance with the Act and its regulations.

I understand that any of my personal information provided by me to the Housing Provider is given on the understanding that

the Housing Provider is collecting this information on behalf of the Housing Access Centre for the City of London & County of

Middlesex.

I understand that any inquiries with respect to my personal information may take the form of electronic data exchanges.

I confirm that if I have any questions or concerns about the collection, use or disclosure of my personal information, I should

contact the Manager, Rent Supplement and Tenant Selection of Social Housing for the City of London.

Form no. 3000 (rev.2017-05)

www.london.ca

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 9 of 10

SECTION 9 - Release and consent (continued)

I declare:

I declare that everything I have written in this document is true and that no information that is required to be given has been

withheld or omitted.

I understand that all of my personal information I give to the Housing Access Centre for the City of London & County of

Middlesex and/or the Housing Provider will belong to them.

I understand that only the people I have listed on this document may live with me in subsidized housing.

I understand that the Housing Access Centre for the City of London & County of Middlesex and/or the Housing Provider will

use my personal information that I give them to determine if I am eligible or continue to be eligible for RGI assistance; the

size and type of unit I may be eligible to receive; my placement on waiting lists; and the amount of geared-to-income-rent

payable by me.

I declare that I am in Canada legally.

I understand that I must pay back or arrange to pay any money I may owe to any subsidized housing project before I can be

offered a subsidized unit.

I understand that it is an offence, under the Act for an individual to knowingly obtain or assist a household member to obtain

RGI assistance for which they are not entitled. Such an offence carries a fine and/or imprisonment as well as a prohibition

from re-applying for assistance for a minimum period of two years. If something on this document is missing, incorrect or

false, the Housing Access Centre for the City of London & County of Middlesex and/or the Housing Provider may request

additional information, or may cancel my eligibility for RGI assistance and may request my household to reimburse the

Housing Access Centre for the City of London & County of Middlesex for the amount of RGI assistance paid on behalf of my

household.

I understand that if the Housing Access Centre for the City of London & County of Middlesex and/or the Housing Provider

request a household to reimburse the City of London, the members of the household who are parties to the lease or the

occupancy agreement for the unit are jointly and severally liable to pay the amount owing to the City of London.

I understand that if at any time the circumstances that created eligibility for an Urgent Status no longer exist, I will cease to

qualify for priority status under the Urgent category. However, my application will remain on the Centralized Wait List.

All household members who are over the age of 18 must sign below to indicate they have read and accept all terms and conditions of

the Release and Consent on page 8.

Household member (Please print name.) Signature Date signed

Form no. 3000 (rev.2017-05)

www.london.ca

For office use only

Application for Rent Geared-to-Income Housing

Client number

Housing Access Centre (HAC) for the City of London & County of Middlesex

Citi Plaza | 355 Wellington Street, Suite 248, 2

Floor | London ON N6A 3N7

Tel: 519 661-0861 | E-mail: [email protected]

,Page 10 of 10

Application checklist

Use this checklist to make sure you have attached all the required documents.

Completed all 9 sections of this form.

Signed page 9.

Completed the Building Selection form (number 3001).

Included copies of Canadian birth certificates, valid Canadian passport landed immigrant, permanent resident card or

refugee claimant documents for ALL members of the household.

Documentation verifying all Applicants income and owned assets (if applicable).

If anyone in your household owes money to an Ontario housing provider, attach confirmation that the household member

has entered into an agreement for the repayment of the arrears.

If you have asked for an additional bedroom because a member of your household has a legal custody agreement or

visiting rights involving overnight stays, you must supply a copy of the agreement.

If you have asked for an additional bedroom because of a disability in your household you must attached a detailed

explanation (additional medical verification may be required).

If you have asked for an additional bedroom because someone in the household is expecting a baby, you must

provide proof of pregnancy.

10.

If someone in the household owns residential property that is suitable for year-round occupancy, whether the

property is in or outside of Ontario, you must submit a divestment form.

If you do not complete all sections of this application form or do not attach all the required documents, you will be

advised in writing that your application is incomplete and you will not be placed on the waiting list.

It is important to notify us of any changes in your household size, address and phone number. Your application will be cancelled

if we are unable to contact you. You will have one year to reactivate your application, after which time you will be required to

reapply and your name will be placed at the bottom of the waiting list.

You only have three (3) refusals to an offer of housing, after which, you will cease to be eligible for rent-geared-to-income

assistance and your application will be removed from the waiting list.

Your completed application form and attached documents can be mailed or delivered to:

The Corporation of the City of London

Housing Access Centre

Citi Plaza, 2

Floor

355 Wellington Street, Suite 248

London, ON N6A 3N7

APPLICATIONS WILL NOT BE ACCEPTED BY FAX

We’ve moved!

Our new address is Citi Plaza, 355 Wellington Street, Suite 248 and

is located on the south side of Citi Plaza, on the 2

Floor by the movie theatre, to the right of

the escalator from the Wellington Street entrance

Personal information contained on this form or in attachments is collected, pursuant to the Housing Services Act (2011) Sections

169-176 or the Municipal Freedom of Information and Protection of Privacy Act, (R.S.O. 1990, c M.56). This information will be used to

determine suitability and eligibility for housing applied to, continuation of housing and the appropriate rent scale and rent geared-to- income

charge. Personal information may be disclosed to housing providers, other municipal or provincial departments and agencies that assist in

the provision of social housing and social agencies providing social assistance to the applicant. All applicants must consent to the

verification, disclosure and the transfer of information given on this form and attachments by or to any of the above entities and you are

required to provide supporting material for the purpose of processing the application.

Form no. 3000 (rev.2017-05)