Rent & Utility Assistance Form

Rent/Utility Form

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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

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

Intent to Rent

Signed Lease

Utility Disconnection Notice

Utility Collections Notice (between November 15th to April 30th ONLY)

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. 313 for clarification.

Please provide your "Move In" Date

MM slash DD slash YYYY

Past Assistance

Have you received financial assistance from us in the past?(Required)

Yes

Not Sure

I received assistance

Our 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 programs.

Please contact our office at 519-344-1746 ext. 304 to speak with our intake worker to determine eligibility

Source of Income

What is your source of income? Please select all the 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

Please write your source of income(Required)

If you are receiving OW or ODSP payments or top-ups, please apply for MRB assistance through your worker first BEFORE completing this intake. If you are NOT eligible, written confirmation from your worker will be required as part of the review process.

OW/ODSP Applicants

If you receive Ontario Works (OW) or Ontario Disability Support Program (ODSP), please contact your caseworker before continuing with this application. If you have already contacted your worker, please provide their information below.

Have you contacted your OW/ODSP worker for MRB Assistance?

Yes

Please contact your OW/ODSP worker before continuing with this form. Once you have contacted them, you can return to complete your application.

Worker Name

Worker Email

Date Contacted

MM slash DD slash YYYY

Outcome/Notes

I understand I must contact my OW/ODSP worker before submitting this application.

Yes

This field is hidden when viewing the form

OW/ODSP Follow-Up Required

Yes

Contact Information

Name(Required)

Preferred or Given Last

Date of Birth(Required)

MM slash DD slash YYYY

Spouse/Partner

Do you reside with a spouse/partner?(Required)

Yes

Name

Preferred or Given Last

Spouse Date of Birth(Required)

MM slash DD slash YYYY

What is your spouse's source of income? Please select all the 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

Please write your source of income(Required)

If your spouse/partner is receiving OW or ODSP payments or top-ups, please apply for MRB assistance through their worker first BEFORE completing this intake. If they are NOT eligible, written confirmation from their worker will be required as part of the review process.

Spouse OW/ODSP Applicants

If your spouse/partner receives Ontario Works (OW) or Ontario Disability Support Program (ODSP), please have them contact their caseworker before continuing with this application. If they have already contacted their worker, please provide their information below.

Has your spouse/partner contacted their OW/ODSP worker for MRB Assistance?(Required)

Yes

Worker Name(Required)

Worker Email(Required)

Date Contacted(Required)

MM slash DD slash YYYY

Outcome/Notes(Required)

I understand my spouse/partner must contact their OW/ODSP worker before submitting this application.(Required)

Yes

This field is hidden when viewing the form

OW/ODSP Follow-Up Required

Yes

Number of children in the home(Required)

Please enter a number greater than or equal to 0.

Child #1 Age(Required)

Child #2 Age(Required)

Child #3 Age(Required)

Child #4 Age(Required)

Child #5 Age(Required)

Child #6 Age(Required)

Child #7 Age(Required)

Child #8 Age(Required)

Child #9 Age(Required)

Child #10 Age(Required)

Do you, or any member of your household identify as First Nations?(Required)

Yes

Phone

Email(Required)

Additional Information

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Assistance Needed

What 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 Details

Amount Owing(Required)

Eviction Date(Required)

MM slash DD slash YYYY

This information can be found on the first page of your N4

Utility Arrears

Type of utility (select all that apply)(Required)

Hydro

Water

Gas

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(Required)

MM slash DD slash YYYY

Delete Disconnection Date for Utility #2(Required)

MM slash DD slash YYYY

Last Month's Rent

Amount of rent per month.(Required)

Are utilities included?(Required)

Yes

Partial

Other Services

What 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

Adopt-a-Family

None

Have you completed your taxes for the previous tax year?(Required)

Yes

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?(Required)

Yes

I don't pay hydro where I live

Not sure

This is a monthly rebate deducted directly from your hydro bill total each month.

If there is anything else you think we should know please enter it here.