NIPISSING DISTRICT HOUSING REGISTRY INC.

1 NIPISSING DISTRICT HOUSING REGISTRY INC. Rent Geared-To- Income Application For Social HOUSING in the DISTRICT of NIPISSING For office use only To be eligible for subsidized HOUSING , you must meet all of the following conditions: Date Received: You must be a Canadian citizen, Landed Immigrant or Refugee Claimant. Received By: At least 1 person in your household must be 16 years of age or older. No household member owes money to any social HOUSING provider. If you own a house, you must agree to sell it within 180 days of being housed. You must be able to live independently, and make your own arrangements for supportive services.

2 Any changes to the information provided must be updated within 30 calendar days. NOTE: The information you give us on this form and your attached documents will be used to determine your eligibility for subsidized HOUSING . Some HOUSING providers may need more information. 1. Instructions Please print clearly and in ink. Please fill out all sections of the form. Read and sign the Release and Consent and Declaration form. Return the form to: NIPISSING DISTRICT HOUSING REGISTRY Box 126 Phone: 705-472-2826. 200 McIntyre St. East Fax: 705-472-1901. North Bay, Ontario P1B 8G8. 2. Applicant Contact Information Last Name: First Name: Street Number & Name Apt.

3 No. City Province Postal Code Post Office Box Home Telephone Work/Daytime Telephone ( ) ( )*. Other person to contact Telephone: ( ). Spoken Language(s) Preferred language for correspondence English French Other English French Other Mailing Address (if different than above): * Calls to offer HOUSING are made during office hours. Please ensure that you can be reached during the day. Page 1 of 8 September 2013. Rent Geared-To- Income Application 3. Household Information Please provide information for all persons (including children) who will live in the HOUSING you are applying for.

4 You must report all income for yourself and of any persons 16 years of age and over. This section must be filled out. Date of Gross Source of Income Last Name First Name Sex Relationship Birth Monthly (work, pension, M/F to applicant D/M/Y Income Ontario works, etc.). / / Applicant Social Insurance Number / / Are you a full time student? Yes No / /. Social Insurance Number / / Are you a full time student? Yes No / /. Social Insurance Number / / Are you a full time student? Yes No / /. Social Insurance Number / / Are you a full time student? Yes No / /. Social Insurance Number / / Are you a full time student?

5 Yes No / /. Social Insurance Number / / Are you a full time student? Yes No Is a baby expected? Yes No If Yes, date expected: Do you own a home? Yes No Are you currently living temporarily with family or friends, or in a motel or emergency shelter? Yes No Do all your family members currently live with you? Yes No Are you entitled to receive support payments? Yes No Does anyone in your household require services in order to live independently? Yes No If yes, please specify what type of support service(s) is required and how they are provided. _____. Has anyone in your household been convicted of a criminal offence?

6 Yes No If yes, has a pardon been granted? Yes No 4. Current Landlord Information Name: Street Address: Apartment Number: City: Province: Postal Code: Telephone Number: Date Moved in: Page 2 of 8 September 2013. Rent Geared-To- Income Application 5. Special Priority Status (Domestic Abuse). Special priority on the waiting list is provided to people either suffering from or at risk of household violence. Complete this section only if you are applying for special priority status because of domestic abuse. Please check any of the following that apply to you : I am currently a victim of domestic abuse (you must provide supporting documents from a social worker, health professional, counsellor, clergy, etc.)

7 If yes, please provide a SAFE mailing address and telephone number where you can be contacted: Same as address and telephone number as above; OR: Street Name and Number_____Apt. Number_____. City_____Province_____Postal Code_____. Telephone Number _____Contact Person_____. Unless you are staying at a shelter for abused women, The REGISTRY will contact you for a telephone or a personal interview. Please call the REGISTRY if you cannot be reached by telephone. 6. HOUSING Preferences The size of the unit you qualify for will depend on the size and/or special needs of your household.

8 Do you own a vehicle? Yes No Do you require parking? Yes No Do you or any member of your household have special HOUSING needs due to a serious health reason or disability? Yes No Do you or any member of your household require? Wheelchair Accessible Unit No Carpeting No Stairs Describe any specific requirements: Other _____. Do you have pets? Yes No What kind? Have you or any of the co-applicants ever been a tenant of Subsidized HOUSING in Ontario? Yes No Name of person(s) who lived in social HOUSING : Name, address and city of HOUSING provider: Date Moved In: Date Moved Out: Reason(s) for moving out: Does any person owe arrears to any of the above or any other social HOUSING providers?

9 Yes No If yes, what is the amount owing? Do you have a repayment plan? Yes No Are you or any of the co-applicants currently a tenant of Subsidized HOUSING in Ontario? Yes No If yes, why are you applying to another subsidized HOUSING unit? Reasons: _____. _____. Page 3 of 8 September 2013. 7. Declaration and Consent I/We declare that all information given in this application is correct and complete. I agree that the application and any supporting documents become the property of the NIPISSING DISTRICT HOUSING REGISTRY Inc. and copies of the application and supporting documents may be given to HOUSING providers that I have selected for placement in locations where I prefer to live.

10 I/We agree to provide any supporting material as may be required. I/We understand and agree that if accommodation is provided to me the unit will be occupied by me and the persons listed on this application. Personal information collected by the NIPISSING DISTRICT HOUSING REGISTRY Inc. , pursuant to the HOUSING Services Act 2011, will be used to determine eligibility for HOUSING applied for, placement on the waiting list and to determine my HOUSING subsidy. Pursuant to the Provincial/Municipal Freedom of Information and Protection of Privacy Act, I/we give our consent: To verify information given in this application and I/we authorize any person, corporation or any social agency having knowledge of any such required information to release the information to the NIPISSING DISTRICT HOUSING REGISTRY Inc.