150 Eighth Street Housing Application

Section 1 – Main Applicant Information

(Primary Household Contact)

Name *

Date of Birth (MM/DD/YYYY) *

Sex *

Male
Female
Other
Prefer not to say

Status in Canada (citizen, landed immigrant, refugee claimant) *

Preferred mode of communication (Email, Paper, Braille, Large Print): *

Are you a member of First Nations, Metis or Inuit? *

If "Yes", proof will be required.

Are you homeless or living in a temporary shelter? *

If “Yes”, please provide a mailing address OR a phone number below. If “No”, please complete the following address information in full.

Street Address

Apt. Number

City

Province

Postal Code

Home phone/TTY number

Work phone

Cell phone

Mailing Address (if different from above)

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.

Name *

Relationship *

If from an Agency, name of Agency

Phone Number *

Mailing Address

City

Province

Postal Code

Do you give us permission to talk about your application with this person? *

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)

Name

Relationship to you

Sex

Male
Female
Other
Prefer not to say

Date of Birth (MM/DD/YYYY)

Status in Canada (Canadian citizen, landed immigrant, refugee claimant)

Member of First Nations, Metis or Inuit? (Proof required)

Household Member #3 (Main applicant is #1)

Name

Relationship to you

Sex

Male
Female
Other
Prefer not to say

Date of Birth (MM/DD/YYYY)

Status in Canada (Canadian citizen, landed immigrant, refugee claimant)

Member of First Nations, Metis or Inuit? (Proof required)

Household Member #4 (Main applicant is #1)

Name

Relationship to you

Sex

Male
Female
Other
Prefer not to say

Date of Birth (MM/DD/YYYY)

Status in Canada (Canadian citizen, landed immigrant, refugee claimant)

Member of First Nations, Metis or Inuit? (Proof required)

Household Member #5 (Main applicant is #1)

Name

Relationship to you

Sex

Male
Female
Other
Prefer not to say

Date of Birth (MM/DD/YYYY)

Status in Canada (Canadian citizen, landed immigrant, refugee claimant)

Member of First Nations, Metis or Inuit? (Proof required)

Household Member #6 (Main applicant is #1)

Name

Relationship to you

Sex

Male
Female
Other
Prefer not to say

Date of Birth (MM/DD/YYYY)

Status in Canada (Canadian citizen, landed immigrant, refugee claimant)

Member of First Nations, Metis or Inuit? (Proof required)

Section 3B - Household Information Continued

Do you have any children in the custody of a Children’s Aid Society because you do not have suitable housing? *

Have you or anyone in your household been convicted of an offence related to rent-geared-to-income within the last 2 years? *

Do you, or does anyone who plans to live with you, owe money to any social housing provider in Ontario? *

Section 3C – Details of Arrears (if applicable)

Name of person owing money *

Name of housing provider *

Address of housing provider *

How much money owing? *

Is a written repayment schedule in place? *

If “Yes”, what is the final repayment date?

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.

Main Applicant's Income *

Household Member #2’s Income

Household Member #3’s Income

Household Member #4’s Income

Household Member #5’s Income

Household Member #6’s Income

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.

Main Applicant's Assets *

Household Member #2’s Assets

Household Member #3’s Assets

Household Member #4’s Assets

Household Member #5’s Assets

Household Member #6’s Assets

Section 6 - Number of Bedrooms

How many bedrooms do you need? *

1 Bedroom
2 Bedrooms
3 Bedrooms

Is one of the bedrooms for someone with a disability, their caregiver, or assistive devices/ equipment? *

Section 6B - Special Needs

Do you require a wheelchair-accessible unit? *

Do you or anyone who plans to live with you, require support services in order to live independently? *

Do you or anyone you live with require the support of a DeafBlind Intervenor or an American Sign Language Interpreter? *

Do you require 24-hour in-home support? *

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.

1. Intervenor and/or Interpreter services

Name

2. Acquired brain injury

Name

3. Attendant Care services

Name

4. Consumer Survivor of mental health services

Name

5. Developmentally disabled

Name

6. Frail senior

Name

7. Physically disabled

Name

8. Wheelchair accessible unit

Name

9. Other support service

Name

Physical Disability details

Intervenor and/or Interpreter service agency name

Other Support Services details

Section 7 – Other Important Information

Please explain why you would like to live at CHKC and list any other important information about yourself, family, your disability, current housing situation, need for Intervenor Services, etc., that may be important for the purpose of this application. *

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.

Applicant's Signature *

Spouse's/Co-applicant's signature

Date *

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.

Applicant's Signature *

Spouse’s/Co-applicant’s signature

Date *