Housing Stability Benefit Request ODSP Form

1 Housing Stability Benefit Request ODSP form Name: ODSP Member ID: Date of Birth (DD/MM/YY): ODSP Case Manager: Contact Phone Number: ( ) Permission to leave message: Yes No Current Address or No fixed address: Program Information The Housing Stability Benefit (HSB) is available to help you cover the costs of moving to new Housing , staying in your current Housing , or if you need to move to a different Housing location. HSB is available up to a maximum of: $1,500 in a 2-year period (24 months) if you have one (1) or more dependent children $800 in a 2-year period (24 months) if you have no dependent children However, the Benefit is only issued when you have not exceeded your maximum Benefit amount for HSB or a similar Housing Benefit including CSUMB in the last 24 months.

2 You must show a need for financial support and no other assistance is available. If you have questions about the HSB please speak with staff at the Housing Help Centre. Please tell us about where you are currently living: I am homeless or staying temporarily with others (for example, family members or friends) I am a renter or I own where I live and my rent/mortgage payment is $_____ I am staying at an emergency shelter (Shelter name: _____) I live in supportive Housing or a care facility (Facility name: _____) Please check off the reason for your Request (please provide any documents noted below): Start-Up Costs for Moving to New Housing Please Note: Your Request must be made no later than one month from the date you move.

3 Please attach proof of your new address. I am leaving an institution or emergency shelter (attached discharge papers) I was evicted from Housing (attach eviction notice) I am leaving domestic violence (attach police report if available) My home is not fit to be lived in (attach documents from landlord, health inspector, or doctor) I need to relocate due to fire or flood (attach supporting documents) I am homeless I found more affordable Housing (attach landlord letter) I need to move to another city Other (Please explain below) Non Start-Up Costs I need pest control for bed bugs and I own my home (attach supporting documents)

4 I need to replace items due to bed bugs (attach proof from landlord or health inspector) I need to purchase or rent a generator for health reasons (attach letter from doctor) I need to replace an appliance (attach Special Supports referral) Other (Please explain below) Maintaining Your Existing Residence I received an eviction notice (attach the notice) I received a utility disconnection notice (attach the notice) I need an item to maintain my home (attach supporting documents) Please explain why you need financial assistance: Si vous d sirez traduire ce document en fran ais s il vous pla t contacter 905-546-2424 extension 4329 Start-Up Costs for Moving to New Housing HSB Needed For Cost Office Use Last Month s Rent Deposit Gas/ Hydro Deposit Moving Costs Appliance.

5 Fridge Stove Washer Furniture Adult Beds Bed for Child(ren) Mattresses Dresser HSB Needed For Cost Office Use Generator Kitchen Supplies Table Chair Lamp Clothing Other (please identify) _____ _____ Non Start-Up Costs Please check if need items due to bed bugs HSB Needed For Cost Office Use Replace Mattresses Bed for Child Replace Couch Replace Generator HSB Needed For Cost Office Use Exterminator Costs (own home) Replace Appliance (owned) Other (please identify) _____ Maintaining Your Existing Residence HSB Needed For Cost Office Use Received Eviction Notice Utility Disconnection Notice HSB Needed For Cost Office Use Other (please identify) _____ Application Notification Your application will be reviewed to determine if you meet the criteria and are eligible for this Benefit .

6 You will be notified in writing regarding the decision. Certification and Consent By signing this form I certify that all information provided in this application is true and verification has been provided when available. In accordance with receipt of the HSB, I hereby consent to the collection and disclosure of my personal information for the purposes of administering, verifying, monitoring, and evaluating HSB. I authorize HHC staff to verify with the Ontario Disability Support Program my eligibility for HSB. I authorize HHC and ODSP staff to provide information to OW Special Supports regarding my eligibility for HSB with Utility Arrears through Discretionary benefits .

7 I understand that staff from the City of Hamilton may contact me in the future for the purpose of conducting a follow-up assessment. Applicant Signature: _____ Date of completion (DD/MM/YY): _____ Notice of Collection of Personal Information pursuant to the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) This information is collected under the legal authority of the Housing Services Act, 2011, s. 10 of the Municipal Act, 2001 and the City of Hamilton s Housing Stability Benefit Implementation Plan (report CS12031(a)) as approved by City Council on December 12, 2012. The information will be used for the purpose of administering social Housing programs and the City of Hamilton s Housing Stability Benefit , including for the purposes of determining eligibility and program evaluation.

8 For more information contact Brian Kreps, Housing Services Division, City of Hamilton, at 905-546-2424 ext. 4329 FOR OFFICE USE ONLY OW / ODSP Case Manager: _____ Case Org: _____ Date (DD/MM/YY): _____ BU Make Up Single Couple Number of Dependent Children _____ Dependent Adults _____ HSB Amount: Amount Requested: _____ HSB Amount Available: _____ HSB Approval: Amount Approved: _____ Date Issued (DD/MM/YY): _____ Denial Reason: _____ RE-ASSESSMENT: Reviewer: _____ Date Requested (DD/MM/YY): _____ Outcome: No change to original decision Varied original decision Additional Amount Approved: _____ Date Issued (DD/MM/YY): _____ Comments: _____ _____