Sault Ste. Marie Social Housing Application Centre
Applicant Information Sheet
180 Brock St
Sault Ste. Marie, ON, P6A 3B7
180, rue Brock
Sault Ste. Marie, (Ontario) P6A 3B7
t: (705) 759-7748 | f : (705) 946-5628
www.socialservices-ssmd.ca
Completing the Application
1. Please PRINT all information in ink. Sign and date where required.
2. Current year Notice of Assessment must be submitted with application to be approved for the
Centralized Waitlist (For all applicants 16 years of age and older if applicable).
3. It is your responsibility to notify our office of any changes in your circumstances, including changes
to contact information.
4. If we are unable to contact you using the information provided, your file will be cancelled.
Additional Housing Applications Available
Applications for the Sault Ste. Marie Mental Health Addictions Housing Project
If you self-identify as First Nation Status, First Nation Non-Status, Metis or Inuit, you are also eligible to
apply for subsidized housing through Ontario Aboriginal Housing Services. Applications are also available
in person at 500 Bay Street, Sault Ste. Marie, ON and online at www.ontarioaboriginalhousing.ca
Questions and Answers for Social Housing
Can I choose where I want to live?
Yes. This application lists all the Housing Subsidy
Programs operated by Sault Ste. Marie District
Social Services - Housing Services.
Some subsidy programs have the option to pick a
specific area where you’d like to live, and some
allow you to choose your own accommodations.
How long will it take me to get a unit?
The length of time before a unit becomes available
will vary depending on the program and/or
location(s) you choose. It may take some time
because of the number of individuals on the waitlist
and / or the number of vacancies.
How long will I be subsidized?
Subsidy for the Strong Communities Rent
Supplement Program ends in 2023. The Sault Ste.
Marie District Portable Housing Benefit and Rent-
Geared-to-Income (RGI) Program currently have no
end date. These two programs are continued on a
month-to-month basis as long as the requirements
of the program are continuously met.
Other Places to Apply for Housing
The following list of Federal Housing Providers have their own Application and Waitlist. Feel free to apply at
each individual location.
Neech-Ke-Wehn Homes Inc.
451 Queen Street E. 2nd Floor
Sault Ste. Marie, ON, P6A 1Z5
(705) 759-2652
The Ontario Finnish Resthome Association
(Kotitalo)
725 North Street
Sault Ste. Marie, ON, P6B 5Z3
(705) 945-9987
www.theofra.ca
William McMurray Corporation
619 Wellington Street E.
Sault Ste. Marie, ON, P6A 2M9
(705) 942-2418
Cara Community Corporation
31 Old Garden River Road
Sault Ste. Marie, ON, P6B 5Y7
(705) 942-6055
Urgent Homelessness Status – General Information
Those experiencing urgent homelessness may qualify for priority on the rent-geared-to-income waitlist,
should they meet the definition.
The Housing Programs Tenant Support Worker will assign this status based on the Service Provider
Prioritization Tool (SPDAT) for all of the following situations to qualify for Urgent Homeless Status:
Person(s) who are living on the street (no shelter – absolute homelessness)
Person(s) using the emergency shelter system as their primary residence
Person(s) awaiting release from hospital who cannot return to their former place of residence and
will not be released until suitable housing is found
Person(s) meeting the victim of violence qualifications¹ per the Housing Programs definition
Person(s) living in sub-standard housing which has been condemned by the municipality for example:
property standards violations which require that the unit be vacated in order to complete the work,
confirmed by a court order or an order of the Landlord and Tenant Board.
Each approved applicant(s) will be placed within the category from the highest to lowest score.
¹qualification information available upon request
Sault Ste. Marie Social Housing Application Centre
Application for Subsidized Housing
(Disponible en Français)
180 Brock St, P.O. Box 277,
Sault Ste. Marie, ON, P6A 5L8
180, rue Brock, C.P. 277
Sault Ste. Marie, (Ontario) P6A 5L8
t: (705) 759-7748 | f : (705) 946-5628
www.socialservices-ssmd.ca
Eligibility Requirements for Subsidized Housing
1. At least one (1) member in your household must be 16 years of age or older and must be
able to live independently with or without support services. The application must be signed by
all applicants and co-applicants age 16+.
2. Each member of the household must be a Canadian Citizen, Landed Immigrant, or have
Refugee Claimant Status and have no deportation order under the Immigration and Refugee
Protection Act (Canada) against any member of the household. There also cannot be a
departure order or exclusion order under the Immigration and Refugee Protection Act
(Canada) that has become effective with respect to any member of the household.
3. You must not owe arrears to any social housing provider, or have misrepresented your
household income.
4. If you own a home or any other real estate suitable for year-round occupancy, you must agree
to sell it within 180 days of receiving subsidy.
5. Understanding that all subsidized tenants will be required to pursue all possible sources of
income that they may be eligible for, including Ontario Works, Child Support, Employment
Insurance (EI) and Immigration Sponsorship Support.
6. Once you have accepted one of the available rental subsidies offered by Community Housing
and Development, you will be removed from all waitlists for all rental subsidy programs you
may have applied for.
Pg. 2 of 12
Applicant & Co-Applicant Information
1. – APPLICANT
LAST NAME:
FIRST NAME:
DATE OF BIRTH:
MM/DD/YYYY
GENDER: M F
SOCIAL INSURANCE NO:
APT NO.
STREET NO.
STREET NAME:
PROVINCE:
POSTAL CODE:
CITY/TOWN:
MARITAL STATUS:
Single Married Common Law Divorced Widowed Veteran
CITIZENSHIP:
Canadian Citizen Landed Immigrant
Do you identify as Indigenous?
HOME PHONE:
( )
CELL PHONE:
( )
EMAIL:
2. CO-APPLICANT
LAST NAME:
FIRST NAME:
DATE OF BIRTH:
MM/DD/YYYY
GENDER: M F
SOCIAL INSURANCE NO:
APT NO.
STREET NO.
STREET NAME:
PROVINCE:
POSTAL CODE:
CITY/TOWN:
MARITAL STATUS:
Single Married Common Law Divorced Widowed
CITIZENSHIP:
Canadian Citizen Landed Immigrant
Do you identify as Indigenous?
HOME PHONE:
( )
CELL PHONE:
( )
EMAIL:
RELATIONSHIP TO APPLICANT:
3. HOW CAN WE CONTACT YOU?
Telephone Email Mail
ALTERNATE CONTACT – IN YOUR ABSENCE
NAME:
RELATIONSHIP:
PHONE NUMBER:
( )
MAY WE DISCLOSE INFORMATION REGARDING YOUR APPLICATION WITH THE ABOVE CONTACT? YES NO
4. LIST ALL OTHER PERSONS (INCLUDING DEPENDENTS) WHO WILL BE LIVING WITH YOU.
NOTE: IF EXPECTING A BABY, PLEASE INDICATE DUE DATE. A DOCTOR’S NOTE IS ALSO REQUIRED.
MM/DD/YYYY
LAST NAME
FIRST NAME
DATE OF BIRTH
GENDER
RELATIONSHIP
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
MM/DD/YYYY
DO ALL APPLICANTS AND DEPENDENTS LISTED ABOVE LIVE IN YOUR PRESENT ACCOMODATION?
Yes No
If “If “No”, please explain circumstances:
Pg. 3 of 12
Previous Applications for Social Housing
Have you or anyone else who will be living with you ever lived in a social housing unit in Ontario?
Yes No If YES, please provide the most recent information below:
NAME OF HOUSING PROVIDER:
Special Priority Placement (SPP) – (Optional)
In order to qualify for Special Priority Placement (SPP) you or someone in the household MUST be a current
victim of abuse and/or a survivor of human trafficking. The victim of abuse must have lived with the abuser
within the past (3) months (Complete Section A).The victim of trafficking must be currently trafficked or have
exited trafficking within the past (3) months (Complete Section B).
Please obtain the SPP Reference Sheet which outlines the specific documents that are required
in addition to this application.
SECTION A – APPLYING AS A VICTIM OF ABUSE.
1. I AM APPLYING FOR SPP BECAUSE I, OR SOMEONE IN MY HOUSEHOLD IS CURRENTLY A VICTIM OF ABUSE
Yes No
If YES, please provide name of abuser:
2. I HAVE LIVED APART FROM THE ABUSER FOR LESS THAN (3) MONTHS
Yes No
3. I AM CURRENTLY RESIDING WITH ABUSER
Yes No
If YES, please provide move out date:
MM/DD/YYYY
4. Proceed to SECTION C.
SECTION B – APPLYING AS A VICTIM OF HUMAN TRAFFICKING.
1. I AM APPLYING FOR SPP BECAUSE I, OR SOMEONE IN MY HOUSEHOLD IS CURRENTLY BEING TRAFFICKED.
Yes No
2. I HAVE EXITED TRAFFICKING WITHIN THE PREVIOUS (3) MONTHS
Yes No
If YES, please provide the exit date:
MM/DD/YYYY
3. Proceed to SECTION C.
SECTION C
4. Do you believe that you are at risk of being abused if you attempt to obtain information or documents to support
your request for SPP?
Yes No If YES, please explain:
Special Needs / Modified Housing – (Optional)
Households requesting special needs / modified housing must meet the definition as per the Accessibility for
Ontarians with Disabilities Act, 2005 and the Human Rights Code, R.S.O. 1990.
All Households requesting an accessible unit are required to provide proper documentation to support the
disability of the household member.
This documentation must be obtained in writing by their physician, physiotherapist, social worker or the
agency and/or organization specializing in the specific disability.
I/We require a wheelchair accessible unit
Yes No
Pg. 4 of 12
Available Rent Subsidy Programs in the District of Sault Ste. Marie
Rent-Geared-to-Income (RGI) Program
The RGI Program is designed to provide a rental subsidy for 1 to 5 bedroom Adult and Senior apartments,
townhouses, semi-detached and single family homes located within the District of Sault Ste. Marie. The buildings
and homes are operated by various non-profit housing corporations and co-operatives.
The list of available units can be found on pages 6 through 9 of this application.
I/we wish to apply for the Rent-Geared-to-Income (RGI) Program: Yes No
Sault Ste. Marie District Portable Housing Benefit (1 and 2 Bedroom Units Only)
The Sault Ste. Marie District Portable Housing Benefit provides eligible applicants with a rental subsidy towards
their current private rental unit or a different private rental of their choice.
Eligibility requirements are as follows:
Subsidy is calculated on the average market rent for a 1 bedroom unit at $875.00, or for a 2 bedroom
unit at $975.00.
You must reside in a rental unit and be responsible to pay rent to a landlord
You must not be renting from someone related to you
I/we wish to apply for the Sault Ste. Marie District Portable Housing Benefit: Yes No
Additional Requirements – (Optional)
If you require a main floor apartment, an elevator, or an additional bedroom for health-related issues, complete
the next box. If you require this, you will be excluded from offers for housing that requires the use of stairs.
Medical documentation from a physician or other health professional is required with your application.
I/we require a main floor / elevator Yes No I/we require an additional bedroom Yes No
Pg. 5 of 12
Statement of Monthly Income
All monthly income is all amounts received BEFORE DEDUCTIONS (gross amount) for all persons / family
members who will live in the unit. ALL SOURCES MUST BE DECLARED.
(GST / Child Tax Benefit / Trillium Payments are NOT to be included as a monthly source of income.)
INCOME SOURCES
FOR FURTHER DEFINITIONS OF INCOME,
PLEASE VISIT WWW.SOCIALSERVICES-SSMD.ca
GROSS MONTHLY TOTAL (BEFORE DEDUCTIONS)
APPLICANT
CO-APPLICANT
OTHERS ON
APPLICATION
Ontario Works (Social Assistance)
$
$
$
Ontario Disability Support Program (ODSP)
$
$
$
Full / Part Time Employment
$
$
$
Employment Insurance (E.I.)
$
$
$
Workplace Safety & Insurance Benefits (W.S.I.B.)
$
$
$
Old Age Security (O.A.S.)
$
$
$
GAINS – Aged
$
$
$
Canada Pension Plan (C.P.P.)
$
$
$
Private Pensions
$
$
$
Student Grants / Band Grants and/or Allowances
$
$
$
Ontario Student Assistance Program (O.S.A.P.)
$
$
$
Child Support / Alimony
$
$
$
Other Income (specify):
$
$
$
Statement of Assets
ASSET TYPE
VALUE
APPLICANT
CO-APPLICANT
OTHERS ON
APPLICATION
Bank, Trust Company, Credit Union (savings & chequing)
$
$
$
Stocks, Bonds, GIC’s, Debentures, Term Deposits, etc.
$
$
$
RRSP, Annuities, RRIFS
$
$
$
Rent Revenue
$
$
$
Business Assets
$
$
$
Monies owed to you over $500.00
$
$
$
Life Insurance Policies (interest earned & value)
$
$
$
Other Assets (specify):
$
$
$
Do you or any other person listed on this application own property? ie. house, farm, land, cottage?
Yes No If YES, indicate type of property, address and estimated value:
Have you or any other person listed on this application transferred assets? Yes No
If YES, indicate type of property, address, and estimated value:
$
DATE:
MM/DD/YY
Pg. 6 of 12
Community Housing and Development By-Name List Referral
The By Name List is a real time, data collection tool used to provide information on inflows and outflows of
homelessness, managed by the DSSMSSAB. The BNL includes consenting individuals and families who are
actively experiencing homelessness.
ADMINISTRATIVE DATA
SPDAT Completed: Yes No
Date Competed:
SPDAT Score:
Wiidookadaadiwin Ozhi Completed:
Yes No
Date Completed:
Score:
Referral Source:
ADDITIONAL INFORMATION
(For Office Use Only – For use by the Housing & Homelessness Team)
HOUSING AND HOMELESSNESS DETAILS
Length of Homelessness (Months):
Current Sleeping Arrangements:
Instances of Homelessness in the last year (Enter Dates)
Date Housing Attained:
Housing Type Attained: (Be Specific)
SERVICES
Assigned Agency
Referral Source
Services Connected to:
Pg. 7 of 12
RGI Program Housing Preferences – Singles, Couples and Families
Please read carefully.
Mark an (X) in the bedroom size of the buildings where you would like to live. You will ONLY be offered units you
have selected and for the bedroom size you qualify for.
If you select “Co-op”, you may be required to volunteer your time and/or services within the complex.
Size of Unit:
You must meet the specific housing guidelines outlined in the Housing Services Act (2011).
The largest bedroom size allows one bedroom per person. Spouses are expected to share a bedroom.
I/We Require:
(Specify)
One (1) Bedroom Two (2) Bedrooms Three (3) Bedrooms Four (4) Bedrooms
Five (5) Bedrooms
No
Preferences:
(Optional)
Mark an (X) below if you want to be on the waitlist for all units in a certain area.
ALL Downtown ALL Central ALL East ALL West
Non-smoking units
Elevator in building
Building has Special Needs /
Modified Units
Mark selections below
based on bedroom size
DOWNTOWN SAULT STE. MARIE
BLDG. TYPE
ELEVATOR
NON
SMOKING
HAS SPECIAL
NEEDS/
MODIFIED UNIT(S)
1
588 Albert Street W.
APT
Non-smoking units
Elevator in building
Building has Special Needs /
Modified Units
Mark selections below
based on bedroom size
CENTRAL SAULT STE. MARIE
BLDG. TYPE
ELEVATOR
NON
SMOKING
HAS SPECIAL NEEDS/
MODIFIED UNIT(S)
1
2
3
4
77 Allard Street – Highland Place (Cara III)
APT
Boston Avenue
Town House
Brien/Poplar/McNabb* (Bachelor)
APT
Brien/Poplar/McNabb Streets
APT
Brien/Smale/Crawford/Weldon
Cunningham/Campbell Streets
House
Chapple / Albion Avenue
Town House
53 Chapple Avenue
APT
101 Chapple Avenue
APT
277 Northern Avenue East –
Columbus Club Housing Corp.
APT
31 Old Garden River Rd. – Cara I
APT
59 Old Garden River Rd. – Cara II
APT
58 Pawating Place – Pawating Co-op
Town House
80 Sackville Road – Croatian Village
APT
345 St. George’s Avenue
APT
123 & 131 Willoughby Avenue
4 PLEX
Pg. 8 of 12
Mark selections below
Based on bedroom size
X
EAST SAULT STE. MARIE
BLDG. TYPE
ELEVATOR
NON
SMOKING
HAS SPECIAL NEEDS/
MODIFIED UNIT(S)
1
2
3
4
5
Adrian Drive
SEMI
95 Constellation Place – Orion Co-op
Town House
101 LaChaumiere Place – LaChaumiere Co-op
Town House
22, 68, 84, 133 Murphy Street
House
15, 77 Murphy Street
House
112 River Road
House
Shannon Road / Capp Avenue
SEMI/DUPLEX
539 Trunk Road – Moose Lodge Housing
APT
52/89/104 Willowdale Avenue
House
WEST SAULT STE. MARIE
BLDG. TYPE
ELEVATOR
NON
SMOKING
HAS SPECIAL
NEEDS/
MODIFIED UNIT(S)
1
2
3
4
5
50 Creekside Lane – Vesta Co-op
Town House
11/13/15 Durban Road
House
29 – 41 St. Basil’s Drive
House
676-714 Second Line W.
Town House
1001 Second Line W. – Haldimand Co-op
Town House
415 - 435 Sydenham Road
House
Unit selections for seniors are on the following page.
Pg. 9 of 12
RGI Program Housing Preferences - Seniors
Please read carefully.
The units listed below are for Seniors. You must be at least 60 years of age to live in these units. You may apply if you
will be turning age 60 within 12 months of submitting this application.
Mark an (X) in the bedroom size of the buildings where you would like to live. You will ONLY be offered units you have
selected and for the bedroom size you qualify for.
Size of Unit:
You must meet the specific housing guidelines outlined in the Housing Services Act (2011). The
largest bedroom size allows one bedroom per person. Spouses are expected to share a bedroom.
I/We Require:
(Specify)
One (1) Bedroom Two (2) Bedrooms
No
Preferences:
(Optional)
Mark an (X) below if you want to be on the waitlist for all units in a certain area.
ALL Downtown ALL Central ALL East ALL West
Non-smoking units
Elevator in building
Building has Special Needs /
Modified Units
Mark selections below
based on bedroom size
CENTRAL SAULT STE. MARIE
BLDG. TYPE
ELEVATOR
NON
SMOKING
HAS SPECIAL
NEEDS/
MODIFIED UNIT(S)
1
2
55 Chapple Avenue
APT
277A Northern Avenue E. –
Columbus Club Housing Corp.
APT
725 North Street – Ontario Finnish Resthome,
(Suomi Eesti Maja)
APT
DOWNTOWN SAULT STE. MARIE
BLDG. TYPE
ELEVATOR
NON
SMOKING
HAS SPECIAL
NEEDS/
MODIFIED UNIT(S)
1
2
615 Bay Street
APT
623 Bay Street – Lions Place
APT
4 East Street – Italian Housing Corp. (No Pets)
APT
WEST SAULT STE. MARIE
BLDG. TYPE
ELEVATOR
NON
SMOKING
HAS SPECIAL
NEEDS/
MODIFIED UNIT(S)
1
393 Dovercourt Road – St. Gregory’s
APT
Pg. 10 of 12
Consent, Release & Statutory Declaration
Please read the following consent, release and statutory declaration section carefully, and sign the spaces
below. All people 16 years of age and older who are not full-time students and who are going to live with you
must sign.
RELEASE
1. I/we understand that the Sault Ste. Marie Housing Corporation, the District of Sault Ste. Marie Social Services Administration Board
(DSSAB) and the housing providers to whom I will be applying are authorized to collect personal information on this form in
accordance with sections 65 or 71 of the Housing Services Act, 2011 s.o. 2011, c.6 and that the information will be used to
determine eligibility for rent-geared-to-income, and/or special needs/modified housing. Any questions about the collection of my
personal information should be directed to the Application Centre, Community Housing and Development, 180 Brock Street, Level 2,
Sault Ste. Marie, ON, P6A 3B7 or call (705) 759-7748.
2. I/we understand and agree that the District of Sault Ste. Marie Social Services Administration Board will use the information I give
them for the following purposes:
to find out if I/we qualify for the housing I/we have applied for
to find out if I/we continue to qualify for rent-geared-to-income assistance and/or special needs/modified housing
to find out how much assistance I/we am/are eligible for
for statistical reporting and policy research
3. I/we consent to the release of any information to the District of Sault Ste. Marie Social Services Administration Board about any bank
account, safety deposit box, assets of any nature, or kind held by me/us, or on my behalf of any of my/our dependents or children
temporarily in my care, alone or jointly with any other person in any financial institution.
4. For the purpose of eligibility assessment, I/we allow the DSSAB and the housing providers to whom I/we will be applying to obtain any
credit information about me/us from any credit agency or any other source.
5. I/we allow the DSSAB and the housing providers to whom I/we will be applying to share my personal information without further
notice to me with the Ministry of Municipal Affairs and Housing, the Community Housing and Development Division, other municipal
service managers or district social services administration boards or lead agencies as defined under the Housing Services Act (HSA)
each person or organization providing services by contract to any of them, if it is needed to make decisions or verify my eligibility for
assistance under the HSA, the Ontario Works Act, 1997, the Ontario Disability Support Program Act, 1997 or the Child Care and Early
Years Act, 2015.
6. I/we consent to the DSSAB giving my personal information to the government for enforcing the Income Tax Act (Canada) or the
Immigration act.
7. I/we understand that any of my personal information given by the DSSAB to a government body mentioned above in paragraph 5 or 6
will only be given in accordance with the Housing Services Act, 2011 and its regulations.
8. I/we understand and agree that the DSSAB may cross-reference my/our personal information relating to this housing application with
other municipal data pertaining to my household.
9. I/we understand that this consent will apply to inquiries made relating to my/our initial eligibility for, as well as my/our past and
present receipt of rent-geared-to-income assistance. I/we further understand that any inquiries with respect to my/our personal
information may take the form of electronic data interchanges.
10. I agree to have my name shared on the By Name List, the real time homelessness data collection tool for Sault Ste. Marie. I
understand that my name will be shared with DSSMSSAB and providers in the Coordinated Access System in order to assist with
supports to securing housing. I understand that I may be contacted to be connected to services by supporting agencies.
Notice with respect to the Collection of Personal Information for this application and any supplied documentation
Collected in accordance with the Housing Services Act, S.0. 2011, c. 6, Sched. 1,s.169.1 & c6, Sched. 1, s.169 (1)
Personal Information Protection and Electronic Documents Act
Freedom of Information and Protection of Privacy Act , R.S.O. 1990 ,c. F. 31, as amended & , R.S.O. 1990, c. M.-56 as amended
Municipal Freedom of Information and Protection of Privacy Act
Pg. 11 of 12
DECLARATION
1. I/we understand that all information I/we give to the DSSAB will belong to them and that they will give my information to the housing
providers that I/we apply to.
2. I/we will understand that if a rental accommodation is provided to me/us, that accommodation is to be occupied only by myself, the
co-applicants and any others listed solely on this application.
3. I/we understand that the DSSAB and/or the housing provider that I/we will apply to will use my/our personal information to determine
if I/we am/are eligible or continue to be eligible for RGI Assistance and/or special needs/modified housing; the size and type of unit
I/we may be eligible to receive; my/our placement on waiting lists; and the amount of rent-geared-to-income paid by me/us.
4. I/we declare that I/we am/are in Canada legally.
5. I/we understand that I must pay back or arrange to pay any monies owed to any subsidized housing provider before I can be offered a
subsidized unit.
6. I/we understand that is it an offence, under the Housing Services Act, 2011, for an applicant or any individual to knowingly obtain, or
assist a household member to obtain rent-geared-to-income assistance for which they are not entitled. Such an offence carries up to a
$5,000 fine and/or up to (6) months imprisonment as well as a prohibition from re-applying for assistance for a period of (2) years. If
something on this application is missing, incorrect, or false, the Application Centre, or the housing providers I/we have applied to may
request additional information and/or may cancel the application.
7. I/we understand that if the DSSAB and/or the Housing Providers representing the DSSAB request a household to reimburse the
DSSAB, the members of the household who are parties to the lease or the occupancy agreement for the unit are jointly and severally
liable to pay the amount owing to the DSSAB.
8. I/we will notify the Application Centre within 30 days of any changes in my/our circumstances once I/we are on the waitlist.
9. I/we will notify the appropriate social housing provider within 30 days of any changes in my/our circumstances once I/we are placed
in a housing unit.
10. I/we understand the requirements for reporting all household income and assets and I/we agree to fully comply. I/we have reported
all income received and all assets currently owned and any assets transferred within the last three years by every member of the
household.
11. I/we understand that any member of the household may make a request for an internal review of certain decisions made, with which
I/we do not agree, regarding the application for housing, and if housed, regarding the subsidized tenancy.
12. I/we hereby release the DSSAB, Application Centre, all associated housing providers, any employee, officer, agent or contractor from
any liability or claim arising from the collection, storage, use or dissemination of any information received or collected pursuant to this
Declaration, Release and Consent. In the event that I/we am/are provided with rental accommodation as a result of my/our
application, I/we acknowledge that my/our eligibility shall be reviewed at least every twelve (12) months and that I/we have the same
obligation to provide information required by the review. In the event that I/we am/are provided with rental accommodation, this
Declaration, Release and Consent shall remain in force and be enforceable against me/us by the Application Centre and my/our
housing provider, in addition to any other obligations with respect to Declaration, Release and Consent which may be imposed upon
or agreed to by me/us.
Pg. 12 of 12
Consent, Release & Statutory Declaration – Signatures
I/we have received a copy of the Applicant Information Sheet
All people 16 years of age and older who are not full-time students and who are going to live with you must
sign this.
I/we have supplied the information in this application to the best of my/our knowledge and believe all
statements are true and no information, required to be given, has been withheld or omitted.
Please do not submit this form to the Application Centre without all required signatures.
HOUSEHOLD
MEMBER:
SIGNATURE:
DATE SIGNED:
MM/DD/YYYY
HOUSEHOLD
MEMBER:
SIGNATURE:
DATE SIGNED:
MM/DD/YYYY
HOUSEHOLD
MEMBER:
SIGNATURE:
DATE SIGNED:
MM/DD/YYYY
HOUSEHOLD
MEMBER:
SIGNATURE:
DATE SIGNED:
MM/DD/YYYY
WITNESS:
DATE SIGNED
MM/DD/YYYY
If you have any questions or concerns about the collection, use or
disclosure of your personal information, please contact:
Sault Ste. Marie Social Housing Application Centre
180 Brock Street, PO Box 277
Sault Ste. Marie, ON, P6A 5L8
P. (705) 759-7748 | F: (705) 946-5628
[email protected]
Revision 2022 - 03