Affordable Housing Intake Form

Brantford Native Housing Application

1. Applicant

Name(Required)

First Middle Initial Last

Date of Birth(Required)

Social Insurance Number

Gender(Required)

Native Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Upload Proof of Indigenous Identity(Required)

Drop files here or

Max. file size: 16 MB.

Marital Status(Required)

Are you currently Homeless?(Required)

Yes

If yes, where do you stay?(Required)

Current Address(Required)

Street Address Address Line 2 City Province Postal Code

Mailing Address (if different)

Street Address Address Line 2 City Province Postal Code

Phone

Phone Type

Cell

Home

Work

Phone

Phone Type

Cell

Home

Work

Email Address

Preferred Contact Method(Required)

Phone Call

Text

Is there a person to be notified in case of emergencies?(Required)

Yes

Applicant Emergency Contact Info

Emergency Contact Name(Required)

Relationship to Applicant(Required)

Emergency Contact Number(Required)

Phone Type

Cell

Home

Work

2. Co-Applicant

Are you applying with a Co-Applicant?(Required)

Yes

Name(Required)

First Middle Initial Last

Date of Birth(Required)

Social Insurance Number

Gender(Required)

Native Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Upload Proof of Indigenous Identity(Required)

Drop files here or

Max. file size: 16 MB.

Marital Status(Required)

Are you currently Homeless?(Required)

Yes

If yes, where do you stay?(Required)

Current Address(Required)

Street Address Address Line 2 City Province Postal Code

Mailing Address (if different)

Street Address Address Line 2 City Province Postal Code

Phone

Phone Type

Cell

Home

Work

Phone

Phone Type

Cell

Home

Work

Email Address

Preferred Contact Method(Required)

Phone Call

Text

Is there a person to be notified in case of emergencies?(Required)

Yes

Co-Applicant Emergency Contact Info

Emergency Contact Name(Required)

Relationship to Applicant(Required)

Emergency Contact Number(Required)

Phone Type

Cell

Home

Work

3. Family Members

Are there other family members that will reside in the Accomodation Applied for?(Required)

Yes

Name

First Last

Relationship

Date of Birth

Gender

Native Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Name

First Last

Relationship

Date of Birth

Gender

Native Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Name

First Last

Relationship

Date of Birth

Gender

Native Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Name

First Last

Relationship

Date of Birth

Gender

Native Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Name

First Last

Relationship

Date of Birth

Gender

Native Ancestry(Required)

First Nations

Indigenous

Metis

Inuit

Do all family members reside in present accommodation?(Required)

Yes

If no, give current address and reason for separation:(Required)

4. Accommodation

Which accommodation size do you require?(Required)

Is there a requirement for a modified or accessible unit?(Required)

Yes

If yes, please specify(Required)

5. Previous Landlords

List your previous landlords over the past five years

Previous Address

Landlord's Name

Landlord's Number

Move In Date

Move Out Date

Was the unit Market Rent or Geared to Income?

Market Rent

Geared to Income

Previous Address

Landlord's Name

Landlord's Number

Move In Date

Move Out Date

Was the unit Market Rent or Geared to Income?

Market Rent

Geared to Income

Please include all other previous addresses within the last 5 years if applicable. Include the same information as requested above.

6. Current Housing Financial Information

Move In Date

Number of Bedrooms

Do you pay full rent or shared?

I Pay Full Rent

I Share Rent

Rent Amount

Hydro Payment

Water Payment

Other Utility Payments

Are you under notice to vacate your home?

Yes

If Yes, Why?(Required)

Landlord Name

Landlord Number

How much notice must you give before moving out?

30 Days

60 Days

90 Days

No Notice

7. Total Monthly Household Financial Information

Please declare all sources of income of those in the household and provide proof of each

Check our definitions and examples of income for more information

Definition of Income

More information

Definitions of Income are as follows:

“Income” means all income, benefits and gains, of every kind and from every source including, but not limited to the following:

Gross salaries, wages, overtime payments, commissions, bonuses, tips, gratitude’s
Grants, scholarships or bursary payments
The gross amount of alimony, separation, maintenance or support payments
The gross amount of unemployment insurance benefits
The gross interest income from savings or chequing accounts in a bank, trust company or credit union
An assigned income equal to the total appraised value of all assets which do not produce interest income multiplied by the rate of return set by the Landlord from time to time
The greater of the net income from the business or total withdrawals from the business as personal salary or other benefits of anyone who is self-employed in a business
The gross amount of workers’ compensation payments or other industrial accident insurance payments made because of illness or disability
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
The gross amount of any old age security, federal guaranteed income supplement and spouse’s allowance and financial assistance under the Ontario Disability Support Program (ODSP)
The gross amount of every kind of pension, allowance, benefits and annuity whether from a federal, provincial or municipal government of any level of government of any country or state or from any other source
The gross amount of gains from investments including interest on dividends, stocks, shares and other securities, and where the actual income can not be determined, an assigned rate of return set by the Landlord from time to time

“Gross Household Income” means the combined income of:

The tenant and every person residing in the leased properties;
Every tenant on the lease temporarily resident elsewhere.

“Spouse” means two people who:

Are married to one another or who represent that they are married to one another; or
Not being married to one another evidence and intention to cohabit in a relationship of permanence or represent that they intend to do so.

Examples of Income

More information

Examples of Income

Employment

Full Time	Seasonal	Commissions	Disability Pay
Part Time	Odd Jobs	Overtime Earnings	Sickness Pay
Irregular Payments	Casual	Tips and Gratitude’s	Shift Bonuses
Yearly or Seasonal Bonuses	Long Term Income Protection Payments	Cost of Living Bonuses	Separation/Vacation Pay

Self-Employment

Tutoring

Taxi

Child Care/Babysitting

Business

Pensions & Allowances

Old Age Security	Widow’s Pension	Training Allowances	Guaranteed Income Supplement (GIS)
Company Pension	Retraining Allowances	Guaranteed Annual Income Systems (GAINS)	Private Pension
War Veteran Allowances (DVA)	Canada Pension Plan	Social Security (other countries)	Disability Pension

Other Income

Worker’s Compensation Payments	Payments from Children’s Aid Society
Insurance Payments	Support from Relatives or Other Sources
Student Grants	Employment Insurance Commission Payments
Provincial or Municipal Payments	Separation/Support/Alimony Payments
Payments under compensation for Victims of Crime Act	One Time Lump Sum Payments (inheritances, court and out of court settlements)

Income Producing Assets

Farm Property which produces income	Life Insurance (cash surrender value)
Real Estate (residential, commercial, cottage, mobile, home)	Real Estate (house, condo, farmland, vacant land
Savings Accounts	Collection of, or investments in, other valuable non-income producing assets
License, which produces income	Business Interests
Business interest which produces income	Registered Retirement Savings Plan (RRSP)

Proof: Bank Record or Last Cheque

Drop files here or

Max. file size: 16 MB.

Applicant Current Employer

Phone Number

Position

Hours

Full-Time

Part-Time

Temporary

Hourly Rate

Co-Applicant Current Employer

Phone Number

Position

Hours

Full-Time

Part-Time

Temporary

Hourly Rate

8. Previous Application and Tenancy

Has anyone on this application previously applied for subsidized rental housing in Ontario or with BNH?(Required)

Yes

If yes, name used on the application

Agency Applied to

Date Applied

Has anyone on this application previously lived in subsidized rental housing in Ontario or with BNH?(Required)

Yes

If yes, name used on the application

Agency Applied to

Date Applied

Address

Reason for Leaving

Move in Date

Move Out Date

9. Consent and Authorization

I give my consent and authorization to Brantford Native Housing:

To disclose the information given on this form to non-profit housing corporations/co-operative local housing authorities, other municipal, provincial and federal departments and agencies that assist in the provision of affordable housing and social agencies providing social assistance to me and persons listed on this application.

To make inquiries to verify the information given in this application and I authorize any person, corporation or any social agency having knowledge of any such required information to release the information to Brantford Native Housing.

To disclose any information in my file to Credit Bureaus and Collection Agencies regarding arrears during and after my tenancy with Brantford Native Housing.

To make inquiries to past landlords regarding my tenancy.

To provide information to future landlords about my tenancy with Brantford Native Housing.

To make inquiries to Credit Bureau and Collection Agencies regarding my financial circumstances

I have read and understand the meanings of “income” and “gross household income” as per the Definitions of Income above. The information I have given on this application for housing is true and correct to the best of my knowledge.

I understand that if I get housing, only the people I wrote down on this form can live with me. I, also, must report any changes in number of people who live with me, AND any changes to my income.

Questions about this consent and authorization should be directed to:

Brantford Native Housing – 318 Colborne St East, Brantford, ON N3S 3M9
TEL; (519)756-2205 or FAX (519)756-1764

Applicant's Signature(Required)

Date(Required)

Co-Applicant's Signature(Required)

Date(Required)

10. Consent Form

What is “Personal Information?”

Personal information includes any factual or subjective information. Recorded or not, about an identifiable individual.

This includes information in any form, such as:

Age, Name, ID Numbers, Income, Assets, Household Composition, Residency Status, Rent Payment Record, etc.
Opinions, Evaluations, Comments, Social Status, Disciplinary Actions; and
Employee Files, Credit Records, Loan Records, Medical Records, Existence of a Dispute between a landlord and a tenant, Intentions (i.e, to acquire goods and services, or change jobs).

Personal Information does not include the name, title, business address or telephone number of an employee of an organization.

Collection and Use of Your Personal Information

Brantford Native Housing will collect, retain and use the personal information provided by you in this form and its attachments for the following purposes:

Considering your application for tenancy;
Verifying the information that you have provided in your application and its attachments relating to the administration and processing of your application for tenancy;
Calculating your rent;
For collection of your rent;
Meeting legal and regulatory requirements arising out of or relating to your tenancy;
For the use of Brantford Native Housing’s auditor to verify our financial records;
For the purpose of contacting necessary services or your contact person in case of an emergency;
For the purpose of making repairs or renovations to the housing unit;

The Executive Director of Brantford Native Housing, located at 318 Colborne St East, Brantford, Ontario N3S 3M9, (519)756-2205 can answer questions and respond to complaints about the collection, use or disclosure of the information.

Brantford Native Housing will disclose the personal information provided by you in this form to the following parties for the purposes described above;

To any social agency providing any form of assistance to you, or other government subsidy under the Ontario Works Act 1997, the Ontario Disability Support Program Act 1997, or any government department responsible for social housing programs under the Social Housing Reform Act, or Brantford Native Housing’s housing portfolio operating agreement;
To the Government of Canada, a department, ministry or agency of it, without further notice to me if the information is necessary for the purpose of administration or enforcing the Income Tax Act(Canada) or the Immigration Act;
To any agent working on behalf of Brantford Native Housing for the purpose of complying with the Social Housing Reform Act;
To any agent/contractor working on behalf of Brantford Native Housing to make repairs or improvements to the house or unit;
To relevant agencies or contact person in case of an emergency;
To credit bureaus and other businesses or individuals that provide credit or rental history information about you;
To a third party in connection with the potential or actual sale, reorganization, merger, consolidation or disposition of the business of Brantford Native Housing;
To the City of Brantford – Housing Department for any damage or rental arrears left after vacating the house or unit;
To Financial Institutions for the collection of rent.

Consent

I authorize and agree that Brantford Native Housing may collect, use and disclose the personal information that I have provided in this form and its attachments as described above as well as disclose of personal information. I understand and acknowledge that, in addition to foregoing, Brantford Native Housing will also collect, use and disclose my personal information as required or permitted by law.

Signature

Date

Signature

Date

Signature

Date

Signature

Date

Signature

Date

To be signed by all household members living in the unit who are sixteen years or older.

Brantford Native Housing Application

1. Applicant

Applicant Emergency Contact Info

2. Co-Applicant

Co-Applicant Emergency Contact Info

3. Family Members

4. Accommodation

5. Previous Landlords

6. Current Housing Financial Information

7. Total Monthly Household Financial Information

Definitions of Income are as follows:

Examples of Income

Employment

Self-Employment

Pensions & Allowances

Other Income

Income Producing Assets

7.1 Employment Income

7.2 OW/ODSP

7.3 Employment Insurance (E.I)

7.4 Canada Pension (CPP)

7.5 Self-Employment

7.6 Old Age Security (OAS)

7.7 Worker's Comp (WSIB)

7.8 Assets

7.9 Other Pensions

7.10 Other Income

8. Previous Application and Tenancy

9. Consent and Authorization

10. Consent Form

What is “Personal Information?”

Collection and Use of Your Personal Information

Consent

INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED

Hotinohsioni Inc.

Brantford Native Housing Application

1. Applicant

Applicant Emergency Contact Info

2. Co-Applicant

Co-Applicant Emergency Contact Info

3. Family Members

4. Accommodation

5. Previous Landlords

6. Current Housing Financial Information

7. Total Monthly Household Financial Information

Definitions of Income are as follows:

Examples of Income

Employment

Self-Employment

Pensions & Allowances

Other Income

Income Producing Assets

7.1 Employment Income

7.2 OW/ODSP

7.3 Employment Insurance (E.I)

7.4 Canada Pension (CPP)

7.5 Self-Employment

7.6 Old Age Security (OAS)

7.7 Worker's Comp (WSIB)

7.8 Assets

7.9 Other Pensions

7.10 Other Income

8. Previous Application and Tenancy

9. Consent and Authorization

10. Consent Form

What is “Personal Information?”

Collection and Use of Your Personal Information

Consent

*INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED*

INCOMPLETE APPLICATIONS WILL NOT BE ACCEPTED