DISTRICT OF COCHRANE SOCIAL SERVICES ADMINISTRATION BOARD
HOUSING SERVICES ACCESS
For Office Use Only:
Primary Provider: ______
Date application Received: ______Time: ______Received By: ______
Please indicate if you are interested in:
a) Rent Geared to Income (Subsidized Rent)
b) Market Rent (Non-subsidized Rent)
c) Number of Bedrooms required ______/ Yes ______No ______
Yes ______No ______
This copy will serve to acknowledge receipt of your application by the District of Cochrane Social Services Administration Board, Housing Services Access, and to acknowledge that your application is:
Complete or Incomplete.
If “Incomplete” is circled, please fill in the highlighted areas on the application and / or provide the missing information, as requested. If “Complete” is circled, retain this for your records. If you have any questions, please call the Housing Services nearest you.
PLEASE READ THE FOLLOWING, COMPLETE THE NAME AND ADDRESS BELOW
THEN YOUR SIGNATURE IS REQUIRED
COLLECTION OF PERSONAL INFORMATION CLAUSE
Personal information contained on this form or in attachments, including form 1, is collected by the District of Cochrane Social Services Administration Board pursuant to Sections 162, 163, 164, 165 and 166 of the Social Housing Reform Act, 2000, and will be used to determine suitability and eligibility for housing applied for, continuation of housing and the appropriate rent scale and rent-geared-to-income charge. Personal information may be released to the housing provider, the government of Canada, including Canada Customs & Revenue Agency, other municipal/provincial and federal departments and agencies who assist in the provision of affordable housing and to social agencies and government agencies providing social assistance to the tenant. The tenant consents to the verification, disclosure, and transfer of information given on this form and attachments by or to any of the above entities and will provide any required supporting material. Questions about this collection should be directed to the Housing Services of the District of Cochrane Social Services Administration Board.
Freedom of Information Contact Person:
Barb Millions, Ontario Works Supervisor, Suite 120, 38 Pine St. N., Timmins, ON P4N 6K6
Declaration
I/we make the above, the following and all other, whether verbal or written, representations, to the District of Cochrane Social Services Administration Board Housing Services, knowing that they will be relied upon by the District of Cochrane Social Services Administration Board Housing Services and its member-housing providers, to assess by qualifications for rental subsidy accommodation and to establish rent.
- I have read the definition of Income and Gross Family Income on the following page and I fully understand them.
- The information given on this form is accurate and complete as requested.
- I understand that if rental subsidized accommodation is provided to me, that accommodation is to be occupied only by myself and “those persons listed in the STATEMENT OF HOUSEHOLD COMPOSITION” subject to approval.
I give consent and authorization to the District of Cochrane Social Services Administration Board Housing Services to:
- Make any inquiries that it deems necessary to verify the information given in this form (including a credit or landlord check, if applicable) and I authorize any person or Social Agency having knowledge of any such information to release the information to the District of Cochrane Social Services Administration Board Services.
- Disclose the information given by me to the District of Cochrane Social Services Administration Board Housing Services, to any Social Agency providing any form of service to me or to any housing provider associated with the District of Cochrane Social services Administration Board Housing Services.
- Information will not be disclosed to any other party, except in accordance with provisions of the FIPPA, MFIPPA, PHIPA, PIPEDA.
- For the purposes of PHIPA, I give consent for the collection of health information to District of Cochrane Social Services Administration Board Housing Services for the purpose of assessing eligibility. The consent is valid until all matters relating to eligibility are resolved to the satisfaction of the District of Cochrane Social Services Administration Board Housing Services.
- The District of Cochrane Social Services Administration Board Housing Services voluntarily complies with the Federal Privacy Information Protection and Electronics Documents Act 2000 (PIPEDA), which applies to the standards for personal information with respect to commercial activity.
Applicant Signature / Date / Witness Signature
Co-Applicant Signature / Date / Witness Signature
Co-Applicant Signature / Date / Witness Signature
Name: ______
Address: ______
MINUTEMANPRESS50200-2Z55
Page 1 of 11
Definition of Income
“Income” means all income, benefits and gains, of every kind and from every source including, but not limited to the following:
a) gross salaries, wages, overtime payments, commissions, bonuses, tips, gratuities;
b) grants, scholarships or bursary payments;
c) the greater of the net income from the business or the total withdrawals from the business as personal salary or other benefits of anyone who is self-employed in a business;
d) the gross amount of unemployment insurance benefits;
e) the gross amount of workers’ compensation payments or other industrial accident insurance payments made because of illness or disability;
f) the gross amount of any old age security, federal guaranteed income supplement and spouse’s allowance and financial assistance under the Ontario Guaranteed Annual Income System (GAINS);
g) the gross amount of every kind of pension, allowance, benefit and annuity whether from a federal, provincial or municipal government of Canada or any level of government of any other country or state or from any other source;
h) the gross amount of alimony, separation, maintenance or support payments;
i) the gross amount of gains from investments including interest on dividends, stocks, shares other securities, and where the actual income can not be determined, an imputed rate of return set by the Ministry of Housing from time to time;
j) the gross interest income from savings or chequing accounts in a bank, trust company or a credit union;
k) the gross amount of interest earned or payable from bonds, debentures, term deposits or investments, certificates, mortgages, capital gains or lump sum payments or other assets;
l) an imputed income equal to the total appraised value of all assets which do not produce interest income multiplied by a rate of return set by the landlord from time to time.
“Gross Family Income” means the aggregate income of:
1) the tenant and every person residing in the leased premises;
2) every tenant on the lease temporarily resident elsewhere.
“Spouse” means:
1) a couple who are married to one another or who represent that they are married to one another;
2) a couple who not being married to one another, evidence an intention to cohabit in a relationship of permanence or represent to the landlord that they intend to do so.
Examples of Possible Sources of IncomeEmployment
- Full-time
- Part-time
- Irregular
- Casual
- Seasonal
- Odd Jobs
- Shift Bonuses
- Yearly/Seasonal Bonuses
- Disability Pay
- Overtime Earnings
- Commissions
- Tips and Gratuities
- Cost of Living Bonuses
- Sickness Pay
- Long Term Income Protection Payments
- Separation / Vacation Pay
Self-Employment
- Tutoring
- Music Teaching
- Child Care
- Babysitting
- Taxi
- Business
Pensions and Allowances
- Old Age Security (OAS)
- Guaranteed Income Supplement (GIS)
- Ontario Disability Support Plan (ODSP)
- Canada Pension Plan (CPP)
- Quebec Pension Plan
- Social Security (other countries)
- Widow’s Pension
- Company Pension
- Private Pension
- Public Service Pension
- Civilian War Pension
- Disability Pension
- War Veteran’s Allowance (D.V.A.)
- War Veteran’s Allowance (other countries)
- Military or Militia or Civil Defense Allowances
- Canada Manpower Retraining Allowance
- Training Allowances
- Retraining Allowances
Other
- Payments from Official Guardian or Public Trustee
- WSIB
- Insurance Payments
- Provincial or Municipal Payments (O.W.)
- Unemployment Insurance Commission Payments
- Payments under Compensation for Victims of Crime Act
- Payments from Children’s Aid Society or Catholic Children’s Aid
- Separation Payments
- Alimony Payments
- Support Payments (for spouse or child)
- Support from relatives or other sources
- One-time lump-sum payments (inheritances, court and out of court settlementS)
- Mortgage Income
- Student Grants
Income Producing Assets / Non-Income Producing Assets
- Farm property which produces income
- Life Insurance (with a cash surrender value)
- Real Estate (residential, commercial, farmland, cottage, mobile home) which produces rental income
- Registered Retirement Savings Plan
- Real Estate (house, condominium, summer cottages, farmland, commercial or vacant land)
- Savings Accounts (bank, trust company, credit union), annuities, Guaranteed Investment Certificates, stocks or shares, bonds, debentures, mortgages, loans, notes,
- Collection of, or investments in other valuable non-income producing assets
- Licence which produces income (e.g. Taxi Licence)
- Business interest which does not produce income
- Business interest which produces income
Page 2 of 11
COCHRANE DISTRICT SOCIAL SERVICES ADMINISTRATION BOARD HOUSING SERVICES ACCESS
(Make a complete list of the persons who will be living in the home for which you are applying.)
APPLICANT
Last Name: ______First Name: ______
YR MTH DY M F
Social Insurance Number: ______Birth Date: _____|____|____ Sex ______
Street & Number: ______Apt. No: ______City: ______
Mailing Address (if different from above): ______
Province: ______Postal Code: ______Home Telephone: ______
Are you a: Canadian Citizen Landed Immigrant Refugee/Applicant Status Indian/Metis Other
Present Marital Status: Married Single Widowed Divorced Separated Common-law Other
Employer: ______Address: ______Phone: (_____) ______
Date Employment Started: ______
CO-APPLICANT
Last Name: ______First Name: ______
YR MTH DY M F
Social Insurance Number: ______Birth Date: _____|____|____ Sex ______
Street & Number: ______Apt. No: ______City: ______
Mailing Address (if different from above): ______
Province: ______Postal Code: ______Home Telephone: ______
Are you a: Canadian Citizen Landed Immigrant Refugee/Applicant Status Indian/Metis Other
Present Marital Status: Married Single Widowed Divorced Separated Common-law Other
Employer: ______Address: ______Phone: (_____) ______
Relationship to Applicant: ______
B. Other Household Members to Live in Home for Which you Are Applying
(If any of your children do not live with you all the time, place an X in the box next to their name(s).)
Last Name / First Name / X / Birthdate / Sex / Relationship
Year / Month / Day / M / F
Person to contact in case of emergency, (next of kin, sponsor, doctor).
1. Name:______Relationship: ______Phone No.: (_____) _____-______
2. Name:______Relationship: ______Phone No.: (_____) _____-______
3. Doctor:______Phone No.: (_____) _____-______
Page 3 of 11
C.
Present Housing Circumstances
Number of bedrooms required: ______
Do you have a physical/medical condition that is aggravated by your current living situation? Yes ___ No ___
If yes, please explain:
______
Do you require or anticipate a modified/wheelchair accessible unit for a disability? Yes ___ No ___
If yes, please explain
______
Do you require supportive housing or
life skills? Yes ___ No ___
Are you homeless? Yes ___ No ___
Are you a victim of domestic abuse? Yes ___ No ___
Is your family separated due to lack of
affordable housing? Yes ___ No ___
Parking Required? Yes ___ No ___
Problem with stairs? Yes ___ No ___
Problem with elevator? Yes ___ No ___
Are you under notice to vacate your home now?
Yes ___ No ___
If yes, please explain:
______
______
______
Are you living with family or friends, or in a motel or hotel or emergency shelter? Yes ___ No ___
Other, please specify:
______
If yes, please explain:
______
______
Do you anticipate a change in the number of people in your household? Yes ___ No ___
D.
Present and Previous AccommodationsPresent Landlord: ______
Landlord’s Phone Number: (_____) ______
How long have you lived at this address? ______
Your former Landlord: ______
Former Landlord’s phone: (_____) ______
Your Former Address: ______
______
Dates From: ______to ______
Did you or the co-applicant ever own a home? If yes,
when did you stop owning it?
______/ Have you or the co-applicant ever lived in a co-op, non-profit, or government housing in Ontario? Yes ___ No ___
If yes, provide the following:
Name of Provider: ______
Address: ______
Phone Number: ______
What Date? ______
E. TOTAL MONTHLY HOUSEHOLD INCOME (Gross monthly income before deductions.)
Please note: You must state all sources of income of those in your household and provide
proof of each if you are applying for Social Housing.
Name:
Source Proof / Applicant / Co-Applicant / Other: / Other:Employment(Most recent cheque stubs)
Hourly Rate:____ Average Hrs Per Week: ____
Social Assistance (Attach stub and drug card)
Specify:
Ontario Works (O.W.)
Ontario Disability Support Plan (ODSP)
Ontario Student Assistance Program (OSAP)
Employment Insurance (EI) (Most recent cheque)
Canada Pension Plan (Bank record or last cheque)
Old Age Security (OAS)(Bank record or last cheque)
Support/Alimony (Supporting legal documents)
WSIB (Most recent cheque)
Assets (Attach description)
Other Pensions (Bank record or last cheque)
Other Income (Bank record or last cheque)
Page 4 of 11
If you are applying for market rent, disregard F. and G.
F. ASSETS
Bank account
______
Bank Name Branch AddressAccount Number
Bank Accounts / Amount / Monthly Income (Interest)Savings
Chequing
Other Accounts (Trust Companies, Credit Unions)
Bonds/Savings Certificates
Annuities, Shares, Securities, Stocks, Debentures
Rent Revenue
Other (Specify e.g. Mortgage)
Total Monthly Income / $ / $
Are you a property owner? Yes ____ No ____ If yes, give type, value and location:
Do you own a business? Yes ____ No ____ If yes, give details:
G. Statement of Non-Income Producing Assets
Value / ValueApplicant / Co-Applicant
a) House / $ / $
b) Cottage
c) Other Real Estate
Sub-Total / For Office Use Only
Less: Amount Of Mortgage Outstanding / Imputed Return
Net Assets - Real Estate / Applicant / Co-Applicant
Business Assets (Partnership, etc.)
Monies Owed To You (Amounts over $500.00)
Paid-Up Life Insurance
Other (Specify)
Total / $ / $ / $ / $ / $
If any assets have been transferred, indicate:
Date of transfer: ______Transferred To: ______
Comments and/or additional information you feel would be pertinent to this application:
Page 5 of 11
/ CDSSABHousing Services / BUILDING SELECTION SHEET
Please Mark With (X) All of your Selections /
Building / Street Address / Building Type / No. of Units / 1 Bedroom / 2 Bedroom / 3 Bedroom / 4 Bedroom / 5 Bedroom / Parking / Garage / Fridge/Stove / Selection
Timmins - Family / Singles
Genesis Housing Co-op / 1065 Bailey Street / T.House + Apts. / 36 / / / C / /
Goldridge Co-operative / 150 Kelly Ann Drive / T.House + Apts. / 44 / / / C / /
Kaleidoscope Co-operative / 1115 McLean Drive Unit 96 / T.House + Apts. / 95 / / / / / C / /
Pins Gris co-operative / 400 Shirley St. Unit 100 / T.House / 40 / / / / C / /
Tisdale Whitney Co-operative / 900 Government Rd Porcupine / T.House / 40 / / / / / C / /
Timmins Rent Suppl. Units Landlord: Riverside Acres / Riverpark Road / T.House
+ Apts. / 27 / / / / C /
Timmins Rent Suppl. Units Cedar Apts. / 641 Cedar St. North / Apt. / 14 / / / C / /
Timmins Rent Suppl. Units Harrower Properties / 101 Kelly Ann / Apt. / 18 / / / C / /
Timmins Rent Suppl. Units 680958 Ontario Ltd. / 520-540 Lonergan / T.House / 6 / / C / /
Timmins Rent Suppl. Units Pheonix Investments / 111 Clifford / Apt. / 1 / / C / /
Timmins Rent Suppl. Units McLean Courts / 691 McLean Drive / Apt. / 12 / / / C / /
Timmins Rent Suppl. Units Landlord: Timcor Leasing / 525 Westmount / T.House / 11 / / / C / /
Timmins Rent Suppl. Units Landlord: 487171 Ontario Inc. / Chartrand Apts. 19 Preston Street / Apt. / 11 / / / A / /
Timmins Rent Suppl. Units Landlord: Martin Lambert / 443-445 Pine St. North / Four-
Plex / 8 / / C / /
CDSSAB, Housing Dept. / Vanier Street / Semi / 5 / / / C /
CDSSAB, Housing Dept. / Denise, Martin and Delia Street / Semi / 6 / / C /
CDSSAB, Housing Dept. / Lemoyne Street / Semi / 12 / / / C /
CDSSAB, Housing Dept. / Suzanne, Randall, Graham, Mountjoy St. / Semi / 12 / / C /
CDSSAB, Housing Dept. / McClinton, Spooner, Louise Streets / House Semi / 6 / / / C /
CDSSAB, Housing Dept. / Randall Street / House Semi / 12 / / / C /
CDSSAB, Housing Dept. / Lamminen Ave. & Emilie St. / T.House / 24 / / / / / C /
CDSSAB, Housing Dept. / Brousseau & Maple St. / Semi / 16 / / / / C /
CDSSAB, Housing Dept. / Sterling Ave, Cedar & Birch St. S. / T.House / 65 / / / / / C /
Kenneth Crescent Non Profit / Kenneth Crescent & Collins / House Semi / 50 / / / / C / /
City of Timmins Non Profit Country Vila / 450 Shirley Street / T.House / 40 / / / / C / /
Unit size available
Some wheelchair accessibleAParking spots available at a cost
Located onsiteBLimited parking spots available
*Walkup - Low rise building with no elevatorCParking available at no charge
Note: Most apartment buildings/townhouses have a party room
CDSSAB, HOUSING SERVICES
TIMMINS AREA
FAMILY / SINGLES
Page 6 of 11
/ CDSSABHousing Services / BUILDING SELECTION SHEET
Please Mark With (X) All of your Selections /
Building / Street Address / Building Type / No. of Units / 1 Bedroom / 2 Bedroom / 3 Bedroom / 4 Bedroom / 5 Bedroom / Parking / Garage / Fridge/Stove / Selection
Cochrane - Family / Singles
CDSSAB - Project OH-1 / 6 & 7th Street
14 & 15th Street / Semi / 30 / / / / C /
CDSSAB - Project OH-3 / 15th Avenue / Semi / 16 / / / / C /
CDSSAB - Project OH-5 / Sybil / Victoria / Semi / 8 / / C /
Cochrane District Housing / 381 & 383 8th Street / Apt. / 22 / / / C / /
Hearst - Family / Singles
Hearst Families / Houle & McManus
Boucher & 70-15th Sts. / House / 9 / / C /
Landlord: Cler-Vican Ltd. / 429 Alexandra Street / Apt. / 3 / / / B /
Landlord: Eddy Denommee / 401, 409, 411 & 417 Prince Street / Apt. / 11 / / B /
Brisson Boulevard / 406 & 408 Brisson Boulevard / Apt. / 8 / / / A /
Place Lambert / Berville Street / T.House / 25 / / / / A /
Place Charbonneau / Berville Street / T.House / 14 / / / / A /
Iroquois Falls - Family / Singles
CDSSAB - Project OH-1 / Union Street / Row / 12 / / / / C /
CDSSAB - Project OH-6 / O’Mara Drive / House / 6 / / C /
CDSSAB - Project OH-101 / Campion Street / Semi / 16 / / / C /
CDSSAB - Project OH-102 / Campion Street / Semi / 12 / / / C /
Kapuskasing - Family / Singles
Winnipeg / Winnipeg Street / Semi / 16 / / / C /
Brunetville / Ontario St. / Cabot St. / Semi / 20 / / / / C /
Singles / Ontario, Brock & Wolfe / Apt. / 20 / / A / /
Family Handicap Accessible / Winnipeg Street / Apt. / 2 / / A / /
Val Albert / Vanier, Mill & Downs Streets / Semi / 18 / / / / C /
Landlord: 862233 Ont. Inc. / Richmond Street / *Walkup / 4 / / / B /
Landlord: M. Lamontagne / 9 Ash Street / Apt. / 2 / / B /
Drury St. Non-Profit Housing / 10 Drury Street / Apt. / 46 / / / A / /
Moosonee - Family / Singles
Moosonee Non Profit / Scattered / Apt.
House / 126 / / / / / / C / /
CDSSAB, Moosonee / Wabun, Wavey, Bay, Moose / Semi & House / 72 / / / / / C /
Mocreebec, Mosse Factory / Trapper, Jolly, Visitor, Clarke / House / 20 / / / / C / /
Val Gagne - Family / Singles
CDSSAB - Project OH-3 / Lessard Street / Row / 10 / / / C /
Unit size available
Some wheelchair accessibleAParking spots available at a cost
Located onsiteBLimited parking spots available
*Walkup - Low rise building with no elevatorCParking available at no charge
Note: Most apartment buildings/townhouses have a party room
CDSSAB, HOUSING SERVICES
COCHRANE HEARST IROQUOIS FALLS KAPUSKASING MOOSONEE VAL GAGNE
FAMILY / SINGLES
Page 7 of 11
/ CDSSABHousing Services / BUILDING SELECTION SHEET
Please Mark With (X) All of your Selections /
Building / Street Address / Building Type / No. of Units / 1 Bedroom / 2 Bedroom / Laundry / Parking / Elevator / Fridge/Stove / Balcony / Selection
Cochrane - Senior (60 Years +)
CDSSAB - Project OH-1 / Villa Genier / Apt. / 10 / / / A / /
CDSSAB - Project OH-2 / 235 13th Avenue / *Walkup / 15 / / / A / /
CDSSAB - Project OH-4 / 436 11th Avenue / *Walkup / 37 / / / A / / /
CDSSAB - Project OH-6 / 437 11th Avenue / *Walkup / 31 / / / A / / /
Fauquier - Senior (60 Years +)
Domaine du Bel Age / 1210 Doyon Street / *Walkup / 16 / / / / A / / /
Hearst - Senior (60 Years +)
Villa Beau-Sejour / 54-8th Street / *Walkup / 24 / / / A / / /
Villa Belle-Rivière / 47-13th Street / *Walkup / 24 / / / A / / /
Place St. Paul / 1015 Edward Street / Apt. / 24 / / / / A / / / /
Iroquois Falls - Senior (60 Years +)
CDSSAB - Project OH-2 / 471 DeTroys / *Walkup / 14 / / / A / / /
CDSSAB - Project OH-4 / 156 Picadilly / *Walkup / 25 / / / A / / /
CDSSAB - Project OH-103 / 628 Majestic / *Walkup / 10 / / / A / / /
Iroquois Falls Seniors Apt. IFSAC Non-Profit / 250 Cambridge Ave. / Apt. / 23 / / / / A / / /
Kapuskasing - Senior (60 Years +)
Grandvue / 32 McPherson Ave. / Apt. / 31 / / / / A / / / /
Bayview Apartments / 12 McPherson Ave. / Apt. / 49 / / / A / / / /
Cedar Grove / 55 Cedar Street / Apt. / 51 / / / A / / / /
Matheson - Senior (60 Years +)
Matheson Seniors / 414-6th Avenue / Apt. / 23 / / / A / / / /
Mattice - Senior (60 Years +)
Villa Missinaibi / 160 Melrose Street / *Walkup / 15 / / / A / / /
Moonbeam - Senior (60 Years +)
Residence des Pionniers / 1 Pelletier Street / Apt. / 19 / / / / A / /
Moosonee - Senior / Singles
CDSSAB, Moosonee / Niska / Apt. / 28 / / C / /
Ramore - Senior (60 Years +) / Singles
CDSSAB - Project OH-1 / 374 McIntyre Street / Apt. / 10 / / / A / /
CDSSAB - Project OH-5 / 375 McIntyre Street / Apt. / 15 / / / A / /
Smooth Rock Falls - Senior (60 Years +)
Villa du Rocher / 92 Ross Road / Apt. / 24 / / / A / / / /
Timmins - Senior / Singles
CDSSAB - Bartleman Apts. / 646 Bartleman Street / *Walkup Apt. / 51 / / / / B / / /
CDSSAB – Sterling Seniors / 33 Sterling Avenue E. / Apt. / 61 / / / / B / / / /
CDSSAB – Melrose Apts. / 491 Melrose Blvd. / *Walkup / 42 / / / B / / /
City of Timmins Non Profit / 77 Mountjoy Street N. / *Walkup Apt. / 32 / / / B / / /
City of Timmins Non Profit / 67 Mountjoy Street N. / Apt. / 61 / / / / C / / / /
CDSSAB-Pine Street N. Apts. / 217 Pine Street North / Apt. / 102 / / / / B / / / /
Le Mirage, foyer des aînés / 44 Borden Avenue / Apt. / 50 / / / A / / /
Timmins Finnish Seniors / 231 Huot St., So. Porc. / Apt. / 30 / / / / C / / / /
CDSSAB - Park Ave. Apts. / 620 Park Avenue / *Walkup
Apt. / 12 / / B / / /
CDSSAB – Lakeview Apts. / 58 Lakeview, So. Porc. / Apt. / 60 / / / B / / /
CDSSAB – Lee Apts. / 255 Lee Avenue / Apt. / 15 / / B / /
CDSSAB – College Apts. / 615 College Street / *Walkup
Apt. / 51 / / C / /
Val Gagne – Senior (60 Years +)
CDSSAB – Project OH4 / Lessard Street / *Walkup / 11 / / / A / / /
Val Rita – Senior (60 Years +)
Villa Rita / 24 Deschenaux St. / Apt. / 10 / / / A / /
Unit size availableAParking spots available at a costBLimited parking spots available