Rent & Utility Assistance Form Step 1 of 7 14% Please complete the form below if you need assistance with rental or utility arrears, or are moving and need assistance with last month's rent.Are you a Lambton County Resident?(Required) Yes No To be eligible to receive assistance through the Rent & Utility program, it is required that you reside within Lambton County.Have you received (select all that apply)(Required) Eviction Notice Utility Disconnection Notice Utility Collections Notice (between November 15th to April 30th ONLY) I have not received any of the above items yet This section does not apply to me To be eligible to receive assistance through the Rent & Utility program, it is required that you have received at least one of the above listed items. If you have received a similar document or are unsure if the document(s) you have qualify, please contact our office at 519-344-1746 ext. 304 for clarification.If you are moving, have you received an intent to Rent or signed lease from your landlord?(Required) Intent to Rent Signed Lease I have not received either of these items yet This section does not apply to me To be eligible to receive assistance through the Rent & Utility program, it is required that you have received at least one of the above listed items. If you have received a similar document or are unsure if the document(s) you have qualify, please contact our office at 519-344-1746 ext. 304 for clarification.Please provide your "Move In" Date MM slash DD slash YYYY Past AssistanceHave you received financial assistance from us in the past?(Required) Yes No Unsure I received assistanceBefore March 2020After March 2020UnsureOur program is a one-time per household assistance only. Please reach out to one of the other community agencies such as Salvation Army or St. Vincent de Paul to see if you are eligible through their programsPlease contact our office at 519-344-1746 ext. 304 to speak with our intake worker to determine eligibility Source of IncomeWhat is your source of income? Please select all that apply(Required) Ontario Works (OW) Ontario Disability Support Program (ODSP) Full-time employment Part-time employment EI - Shortage of work EI - Sickness benefits EI - Maternity benefits Child Tax Benefit Canada Pension Plan (CPP) Old age Security (OAS) WSIB I do not have an income Other Other income(Required) If you receive OW or ODSP payments, or top-ups, please connect with your Case Worker. you will need to request assistance through the Municipality Residency Benefit (MRB) fund before community agencies can look at assistance through their organizations. If your Case Worker indicates that you do not qualify for MRB funding or they can only assist with a portion of the amount, we will require written confirmation from your Case Worker outlining those details. Once you have completed this step, please then connect with us at 519-344-1749 ext. 304 to complete an intake. Contact InformationName(Required) Preferred or Given First Last Date of Birth(Required) MM slash DD slash YYYY Do you reside with a spouse/partner?(Required)NoYesSpouse Name(Required) First Last Spouse Date of Birth(Required) MM slash DD slash YYYY What is your spouse's source of income? Please select all that apply(Required) Ontario Works (OW) Ontario Disability Support Program (ODSP) Full-time employment Part-time employment EI - Shortage of work EI - Sickness benefits EI - Maternity benefits Child Tax Benefit Canada Pension Plan (CPP) Old age Security (OAS) WSIB I do not have an income Other Other income(Required) If you receive OW or ODSP payments, or top-ups, please connect with your Case Worker. you will need to request assistance through the Municipality Residency Benefit (MRB) fund before community agencies can look at assistance through their organizations. If your Case Worker indicates that you do not qualify for MRB funding or they can only assist with a portion of the amount, we will require written confirmation from your Case Worker outlining those details. Once you have completed this step, please then connect with us at 519-344-1749 ext. 304 to complete an intake. Number of children in the home(Required)012345678910Child #1 Age(Required)01234567891011121314151617Child #2 Age(Required)01234567891011121314151617Child #3 Age(Required)01234567891011121314151617Child #4 Age(Required)01234567891011121314151617Child #5 Age(Required)01234567891011121314151617Child #6 Age(Required)01234567891011121314151617Child #7 Age(Required)01234567891011121314151617Child #8 Age(Required)01234567891011121314151617Child #9 Age(Required)01234567891011121314151617Child #10 Age(Required)01234567891011121314151617Do you, or any member of your household identify as First Nations?(Required) Yes No PhoneEmail(Required) Additional InformationAddress(Required) Street Address Address Line 2 City Assistance NeededWhat do you need assistance with?(Required) Rental arrears Utility arrears Last Month's Rent Please provide a brief explanation of the circumstances which lead to your current arrears situation(Required)Rental Arrears - DetailsAmount Owing(Required) Eviction Date – this information can be found on the first page of your N4(Required) MM slash DD slash YYYY Utility Arrears - DetailsType of utility (select all that apply)(Required) Hydro Water Gas This Doesn't Apply To Me Hydro Company(Required) Hydro Amount Owing(Required) Water Company(Required) Water Amount Owing(Required) Gas Company(Required) Gas Amount Owing(Required) Disconnection Date for Utility #1 MM slash DD slash YYYY Disconnection Date for utility #2 MM slash DD slash YYYY Last Month's RentAmount of rent per month(Required) Are utilities included(Required) Yes No Other ServicesWhat Inn programs and services do you use? Please select all that apply(Required) Food Bank Mobile Market Kid's Snack Pack Program Income Tax Program Transit Program (Bus passes/tickets) Backpack Program Winter Coat Drive Birthday Club None Have you completed your taxes for the previous tax year?(Required) Yes No When you do not file your tax return each year, you may be losing out on important benefits and credits owed to you! (Examples: Trillium Benefit, GST, Carbon Tax Incentive etc.) Did you know we have a free tax program that can assist you in filing your taxes for up to the past five tax years? If you are interested in using this free service, please contact our office at 519-344-1746 ext. 301 for more information.Do you receive the Ontario Electricity Support Program (OESP) rebate? (This is a monthly rebate deducted directly from your hydro bill total each month.)(Required) Yes No Unsure I don't pay hydro where I live If there is anything else you think we should know please enter it here.If you would like more information about this program, or to see if you qualify, please contact our office at 519-344-1749 ext. 301 for more information ConsentThe Ministry has recently introduced new rules regarding the collection and sharing of personal data. Service providers, such as The Inn and the County, will collect some personal information and send it, in a modified form, to the Ministry. This data helps prevent and reduce homelessness. People receiving help will need to agree to share their personal information. 1. I consent to the collection of personal information by the Service Provider, on behalf of The Corporation of the County of Lambton and the release of such personal information to The Corporation of the County of Lambton for the purpose of the Homelessness Prevention Program, and more specifically to satisfy the Ministry’s requirements through reporting anonymized data to the Ministry with the goal of addressing and reducing homelessness. 2. Without restricting the generality of the consent in section 1 above, I specifically consent to the collection and release of personal information relating to my name, date of birth, historical use of Provincial institutions, and my demographic status relating to Indigenous status. What this means: You agree to allow us to provide your name, date of birth, history with government services, and Indigenous status to The County of Lambton to help them track and prevent homelessness. Summary of consent: When you submit this application form, your information will be referred to our Community Outreach Worker, who will connect with you directly to discuss the next steps and what supporting documentation will be required for your application. By clicking the SUBMIT button below, you - Confirm you have read and agree to the above information. - Consent, regarding this application, for us to contact your Landlord, Utility Provider, or Case Worker, and other Community Agencies that may also be able to provide support, should the need arise.
