Rent/Utility

Intake form for client help with rental arrears and/or utility shut offs
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Source of Income

What is your main source of income?
OW/ODSP - refer to your caseworker for MRB funding - if not eligible for MRB, ask your caseworker for a letter for have them call us. OTHER - please continue to fill out your information and submit this application for assistance.

Contact Information

Name
Do you identify as First Nations?
Please enter a number from 0 to 10.
Please enter a number from 0 to 18.

Additional Information

Address

Need Help with Rent?

We require your last 30 days of banking, ID for everyone in your household, and a copy of the eviction notice. Over $1000 and no eviction notice? Request an N4 from your landlord. Submit the above documents to jon@theinnsarnia.ca
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Need Help with Utilities?

We require your last 30 days of banking, ID for everyone in your household, and a copy of the disconnection notice. Submit the above documents to jon@theinnsarnia.ca
MM slash DD slash YYYY

Consent

Do you give consent for us to contact the landlord/utility provider/caseworker on your behalf?
Your information will be referred to our Community Outreach Worker. If you have been assisted in the past, it may affect your eligibility. Once all documents have been received (jon@theinnsarnia.ca) your application will be reviewed and you will be contacted with a decision.
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