Section 1 – Main Applicant Information
(Primary Household Contact)
If "Yes", proof will be required.
If “Yes”, please provide a mailing address OR a phone number below. If “No”, please complete the following address information in full.
Section 2 - Alternate Contact
Please list a person we can contact on your behalf if necessary. For example, interpreter, agency, relative, friend, community support worker or case manager.
Section 3 – Household Information
Give the full name of each person who will be living with you. Only the people you identify as members of this household can live with you in subsidized housing. Attach proof of status in Canada for each member of your household.
Household Member #2 (Main applicant is #1)
Household Member #3 (Main applicant is #1)
Household Member #4 (Main applicant is #1)
Household Member #5 (Main applicant is #1)
Household Member #6 (Main applicant is #1)
Section 3B - Household Information Continued
Section 3C – Details of Arrears (if applicable)
Section 4 – Income Information
Please report all income for each member of your household.
Income includes money from:
- Employment (Full-time, part-time, temporary, self-employment)
- Pension income from any private or public sources (including OAS, CPP, GIS, and/or other sources)
- Income from government sources (ODSP, OW, EI, CCB)
- Investment income and interest on savings
Estimate the monthly income (before deductions) for you and each person in your household.
Section 5 – Assets Information
Please report all assets for each member of your household.
Assets include any savings, investments or property that you own such as:
- Guaranteed Income Certificates (GICs)
- Bank accounts
- Registered Retirement Saving Plans (RRSPs)
- Tax Free Savings Account (TFSA)
- A business or business licence
- Real estate such as a house, condo, land, or a farm
Estimate the value of any asset owned by you and each person in your household.
Section 6 - Number of Bedrooms
Section 6B - Special Needs
If “Yes” to any of these questions please fill in Section 6C. We may require proof in some cases, such as a letter from your doctor.
Section 6C – Support Services Required
Please check any of the following that applies to your household and provide the name of the household member who receives the services. If checked for physically disabled, Intervenor or Interpreter services and/or other support services, please provide details at the end of this section.
Section 7 – Other Important Information
Section 8 – Consent to Release
This is your agreement with us. Please read it carefully and sign in the spaces below.
I understand the Canadian Helen Keller Centre will use the information I provide for eligibility purposes.
Section 9 – Declaration
I give my word that everything I have written in this application is correct and complete.
I understand that only the people I have listed here may live with me in subsidized housing.
I give my word that I am in Canada legally. Before I can receive housing, I understand that I must pay back or make arrangements to pay any money I owe to any subsidized housing agency.