Eligibility Assessment printable pdf download

Eligibility Assessment

ELIGIBILITY ASSESSMENT

Please answer the following questions honestly and to the best of your knowledge:

1. Do you currently own a home

Yes ______

No ______

2. How many people are there in your household? (please include ages & genders to help us

determine how many bedrooms are needed)

_____ adults

_____ children

3. What is your present annual household income? (Include all income, other than Ontario

Works or Employment Insurance, for example: Earned incoming, CTB, ODSP, Pension, etc.)

**Please enter all that apply!

$ _____________ Income (Gross)

$ _____________ Child Tax Benefit

$ _____________ ODSP

$ _____________ Pensions

4. What are you presently paying for housing?

rent ______________

heat ______________

hydro _____________

5. How many bedrooms are in your present residence? _________

6. Do you have good credit? Yes _____ No ____

a. If you answered NO please indicate what credit issues you have (ie. Items in ollections,

etc) __________

7. Do you have other assets? Yes_____ No_____

This assessment will be reviewed and you will be contacted by our office for further action should we agree

that you meet the criteria. Please note that this information may be shared with our committee members to

determine if you are eligible and will be kept in a secure location until a decision on your eligibility is made.

Once you have been advised that you are not eligibile this form will be destroyed within 30 days of that date.

Please provide your contact information below:

Name:

___________________________________________________________

Address:

___________________________________________________________

Telephone:

___________________________________________________________

Signature:

______________________________

Please return the completed form to: Fran Deschamps

fdeschamps@habitat4home.ca

2- 40 Pacific Court, London, ON N5V 3K4

519-455-6623 ext. 230 Fax: 519-455-8479

Eligibility Assessment