Rent & Utility Assistance Form

Rent/Utility Form

Step 1 of 11

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.

Assistance Needed

What do you need assistance with?(Required)

Rental arrears

Utility arrears

Last Month's Rent

Have You Received an Eviction Notice?(Required)

Yes

Possible forms can include: - Form N4 (Notice to End your Tenancy Early for Non-Payment of Rent)

Have You Received an Intent to Rent or Signed Lease?(Required)

Yes - Signed Lease

Yes - Intent to Rent

If you are looking for Last Month's Rent for a new rental, it is required for you to have a signed lease or an intent to rent from the landlord/property management company.

Have You Received a Utility Disconnection Notice or a Utility Collections Notice (between November 15th to April 30th ONLY)(Required)

Yes - Disconnection Notice

Yes - Collection Notice (Nov 15th - April 30th ONLY)

To be eligible for Utility Arrears assistance, it is required to have a Disconnection Notice. If it is during the time period of November 15th - April 30th, you can submit a Collection notice from your utility company. The Inn is not permitted to pay arrears without one of these two documents from your utility company.

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

Please provide a brief explanation of the circumstances which lead to your current arrears situation.(Required)

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(Required)

MM slash DD slash YYYY

Disconnection Date for Utility(Required)

MM slash DD slash YYYY

Disconnection Date for Utility(Required)

MM slash DD slash YYYY

Please provide a brief explanation of the circumstances which lead to your current arrears situation.(Required)

Last Month's Rent

Amount of rent per month.(Required)

Are utilities included?(Required)

Yes

Partial

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

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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)

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.