Tenant Application (Page 3 of 4) in pdf

Tenant Application Page 3

6. HOUSEHOLD INCOME

TOTAL MONTHLY HOUSEHOLD INCOME (Total amount before deductions)

You must state all sources of income for each member of your household over the age of 16. Proof of

income is required i.e.: photocopies of pay stubs and/or bank books showing monthly income deposits.

Source of Income

Applicant 1 ($)

Applicant 2 ($)

Other ($) Other ($)

Employment

Ontario Works

ODSP (Ontario Disability

Support Program)

Employment Insurance (EI)

Worker’s Compensation

Guaranteed Income

Supplement

Old Age Security (OAS)

Canada Pension (CPP)

Other Pension

Other Country Pension

Other Income

DECLARATION

Pursuant to the Provincial / Municipal Freedom of Information and Protection of Privacy Act, I give my

consent and authorization to Goodwill Niagara:

1. To make inquiries to verify the information given on this application and I authorize any person,

corporation or any social agency having knowledge of any such required information to release the

information to Goodwill Niagara. I agree to provide any supporting material required for my application.

2. To disclose the information given on this form to non-profit housing corporations, co-operatives, and

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.

3. I understand that if I have any arrears owing to any non-profit or co-operative housing provider and

have not made acceptable payment arrangements, I will be deemed ineligible.

4. I understand that I must advise Goodwill Niagara of any changes in contact information and/or

household composition within 10 days of the change or my application will be cancelled and I must

reapply.

Application2012

Tenant Application Page 3