Application for Housing
DISTRICT OF COCHRANE SOCIAL SERVICES ADMINISTRATION BOARD
HOUSING SERVICES ACCESS

Please provide as much information as possible on yourself and on all family members living with you.
Incomplete applications will be discarded.

* Characters in Red indicate that this information is required before submitting your application. 
RENT YOU ARE APPLYING FOR:* Market Rent Rent-Geared-to-Income Rent
A.  Statement of Household Composition
(Make a complete list of the persons who will be living in the home for which you are applying.)

APPLICANT
Last Name*:    First Name*:
Social Insurance Number*: Birth Date (yr/mth/dt)*:  Sex: M    F 
Street & Number*:  Apt. No:  City*: 
Mailing Address (if different from above):
Province*:  Postal Code*:  Home Telephone*: 
Cell Phone: Your email: 
Are you a*: Canadian Citizen  Landed Immigrant  Refugee/Applicant  Status Indian/Metis Other
Present Marital Status*: Married   Single   Widowed   Divorced   Separated Common-law Other
Employer:  Address:  Phone: 
Date Employment Started:  Position Title:


CO-APPLICANT
Last Name:    First Name:
Social Insurance Number: Birth Date (yr/mth/dt):  Sex: M    F 
Street & Number:  Apt. No:  City: 
Mailing Address (if different from above):
Province:  Postal Code:  Home Telephone: 
Cell Phone: Your email: 
Are you a: Canadian Citizen Landed Immigrant Refugee/Applicant Status Indian/Metis   Other
Present Marital Status: Married   Single   Widowed   Divorced   Separated Common-law Other
Employer:  Address:  Phone: 
Date Employment Started: Position Title:
Relationship to Applicant: 
B.  Other Household Members to Live in Home for Which you Are Applying
(If any of your children do not live with you all the time, place an X in the box next to their name(s).)
 
Last Name
First Name
Birth date
 
Sex
 
Relationship
 X
Year
Month
Day
M
F
Person to contact in case of emergency, (next of kin, sponsor, doctor).

1. Name:   Relationship:    Phone No.: 
2. Name:   Relationship:    Phone No.: 
3. Doctor:   Phone No.: 
C.   Present Housing Circumstances  
Number of bedrooms required ?:
Do you have a physical/medical condition that is aggravated by your current living situation Yes  No
If yes, please explain:

Do you require or anticipate a modified/wheelchair accessible unit for a disability?  Yes No
If yes, please explain:

Are you under notice to vacate your home now ?  Yes  No
If yes, please explain:

Do you require supportive housing or life skills ?  Yes  No
Are you homeless?   Yes  No
Is your family separated due to lack of affordable housing
Yes  No

Are you a victim of domestic violence?  Yes  No
If yes, provide supporting documentation from physician, women's shelter, social worker, or any supporting agency.
 

Parking Required ?*  Yes  No
If parking required, make of vehicle? Year?
Problem with stairs? Yes  No
Problem with elevator?  Yes  No
Do you have a scooter or electric power chair?  Yes  No

Do you have a pet?  Yes  No
If yes, provide details:

Are you living with family or friends, or in a motel or hotel or emergency shelter?   Yes  No

Other, please specify:
If yes, please explain:

Do you anticipate a change in the number of people in your household?
Yes  No

If yes, explain:
 


D.  Present and Previous Accommodations
Present Landlord:
Landlordís Phone Number:
How long have you lived at this address?
Your former Landlord:
Former Landlordís phone:
Your Former Address:
Dates From: to:
Did you or the co-applicant ever own a home?  If yes, when did you stop owning it? 
Have you or the co-applicant ever lived in a co-op, non-profit, or government housing in Ontario?  Yes No

If yes, provide the following:
Name of Provider:
Address: 
Phone Number: 
What Date?

E.  TOTAL MONTHLY HOUSEHOLD INCOME (Gross monthly income before deductions.)
Please note: You must state all sources of income of those in your household and provide 
proof of each.
Definition of Income
Source    (Proof needed)
Applicant
Co-Applicant
Other:
Other:
Employment (Most recent cheque stubs) (Example)
Hourly Rate:  Average Hrs Per Week:
Social Assistance (Attach stub and drug card)
Specify:
Ontario Works (O.W.)
Ontario Disability Support Plan (ODSP) (Example)
Ontario Student Assistance Program (OSAP)
Employment Insurance (EI)(Most recent cheque)
Canada Pension Plan (Bank record or last cheque) (Example)
Old Age Security (OAS)(Bank record or last cheque) (Example)
Support / Alimony (Supporting legal documents)
WSIB (Most recent cheque)
Assets (Attach description)
Other Pensions (Bank record or last cheque) (Example)
Other Income (Bank record or last cheque) (Example)

 

If you are applying for market rent, disregard F. and G.

F.  ASSETS (Example)

Bank account Information    

Bank Name

Branch Address

Account Number
Bank Accounts
Amount
Monthly Income (Interest)
         
Savings
Chequing
Other Accounts (Trust Companies, Credit Unions)
Bonds/Savings Certificates
Annuities, Shares, Securities, Stocks, Debentures
Rent Revenue
Other (Specify e.g. Mortgage) 
 
Total Monthly Income
Are you a property owner?  Yes No    If yes, give type, value and location:
Do you own a business?  Yes No    If yes, give details:
G.  Statement of Non-Income Producing Assets (Example)
 
Total
Value
Value
   
 
Value
Applicant
Co-Applicant
   
a) House
   
b) Cottage
   
c) Other Real Estate
   
Sub-Total
For Office Use Only
Less: Amount Of Mortgage Outstanding
Imputed Return
Net assets - Real Estate
Applicant
Co-Applicant
Business Assets (Partnership, etc.)
   
Monies Owed To You (Amounts over $500.00)
   
Paid-Up Life Insurance
   
Other (Specify)
   
Total 
$ $
If any assets have been transferred, indicate:
Date of transfer:    Transferred To: 
Comments and/or additional information you feel would be pertinent to this application:

BUILDING SELECTION
Please Select Any Checkboxes that Apply
(To have more info on a particular building click on details)
  Street Address Building Type  
Selection
         
Timmins - Family / Singles
Genesis Housing Co-op 1065 Bailey Street T.House + Apts.
Kaleidoscope Co-operative 1115 McLean Drive Unit 96 T.House + Apts. Details
Pins Gris Co-Operative 400 Shirley St. Unit 100 T.House Details
Tisdale Whitney Co-operative 900 Ferguson Rd. Porcupine T.House Details
R.S. Landlord 11 Spruce St. S. Apts. Details
R.S. Landlord 449 Delmonte Street Fourplex Details
R.S. Landlord 101 Kelly Ann Apt. Details
R.S. Landlord 520-540 Lonergan T.House Details
R.S. Landlord 691 McLean Drive Apt. Details
R.S. Landlord 443-445 Pine St. North Fourplex Details
CDSSAB - Housing Services Vanier Street Semi Details
CDSSAB - Housing Services Denise, Martin and Delia Street Semi Details
CDSSAB - Housing Services Lemoyne Street Semi Details
CDSSAB - Housing Services Suzanne, Randall, Graham, Mountjoy St. S. Semi Details
CDSSAB - Housing Services McClinton, Spooner, Louise Streets House
Semi
Details
CDSSAB - Housing Services Randall Street House
Semi
Details
CDSSAB - Housing Services Lamminen Ave. & Emilie St. T.House Details
CDSSAB - Housing Services Brousseau & Maple St. Semi Details
CDSSAB - Housing Services Sterling Ave., Cedar & Birch St. S. T.House Details
Kenneth Crescent Non Profit Kenneth Crescent & Collins House
Semi
Details
City of Timmins Non Profit
Country Vila
450 Shirley Street T.House Details
Cochrane - Family / Singles
CDSSAB - Housing Services 6 & 7th Street - 14 & 15th Street Semi Details
CDSSAB - Housing Services 15th Avenue Semi Details
CDSSAB - Housing Services Sybil / Victoria Semi Details
Cochrane District Housing 381 & 383, 8th Street Apt. Details
Hearst - Family / Singles
Hearst Families Houle & McManus - Boucher & 70-15th Sts. House Details
Cler-Vican Ltd. 429 Alexandra Street Apt. Details
Brisson Boulevard 406 & 408 Brisson Boulevard Apt. Details
Place Lambert Berville Street T.House Details
Place Charbonneau Berville Street T.House Details
Iroquois Falls - Family / Singles
CDSSAB - Housing Services Union Street Row Details
CDSSAB - Housing Services O'Mara Drive House Details
CDSSAB - Housing Services Campion Street Semi Details
CDSSAB - Housing Services Campion Street Semi Details
Kapuskasing - Family / Singles
Winnipeg Winnipeg Street T.House Details
Brunetville Ontario St. / Cabot St. T.House Details
Singles Ontario, Brock & Wolfe Fourplex Details
Family Handicap Accessible Winnipeg Street Apt. Details
Val Albert Vanier, Mill & Downs Streets T.House Details
R.Labelle Queen St. Apt. Details
J.Blais Richmond St. Apt. Details
J.Blais Queen & Byng St. Apt. Details
Drury St. Non-Profit Housing 10 Drury Street Apt. Details
Moosonee - Family / Singles
Moosonee Non Profit Scattered Apt.
House
Details
CDSSAB, Moosonee Wabun, Wavey, Bay, Moose Semi & House Details
Mocreebec, Moose Factory Trapper, Jolly, Visitor, Clarke House Details
Val Gagné - Family / Singles
CDSSAB - Housing Services Lessard Street Row Details
Cochrane - Senior (60 Years +)
CDSSAB - Villa Genier 2301 Genier Rd. Apt. Details
CDSSAB - Pioneer Villa 235  13th Avenue * Walkup Details
CDSSAB - Maple Villa 436  11th Avenue *Walkup Details
CDSSAB - Birch Villa 437  11th Avenue * Walkup Details
Fauquier - Senior (60 Years +)
Domaine du Bel Age 41 Doyon Street Apt. Details
Hearst - Senior (60 Years +)
Villa Beau-Sejour 54-8th Street Apt. Details
Villa Belle-Riviere 47-13th Street Apt. Details
Place St. Paul 1015 Edward St. Apt. Details
Iroquois Falls - Senior (60 Years +)
CDSSAB - Riverview Villa 471 DeTroys * Walkup Details
CDSSAB - Picadilly Apts. 156 Picadilly * Walkup Details
CDSSAB - Golden Villa 628 Majestic * Walkup Details
Iroquois Falls Seniors Apt.
IFSAC Non-Profit
250 Cambridge Ave. Apt. Details
Iroquois Falls Seniors Apt.
IFSAC Non-Profit
142-160 New Circle Apt. Details
Kapuskasing - Senior (60 Years +)
Grandvue 32 McPherson Ave. Apt. Details
Bayview Apartments 12 McPherson Ave. Apt. Details
Cedar Grove 55 Cedar Street Apt. Details
Matheson - Senior (60 Years +)
Matheson Seniors 414 - 6th Avenue Apt. Details
Mattice - Senior (60 Years +)
Villa Missinaibi 160 Melrose Street * Walkup Details
Moonbeam - Senior (60 Years +)
Residence des Pionniers 1 Pelletier Street Apt. Details
Moosonee - Senior / Singles
CDSSAB, Moosonee Niska Apt. Details
Ramore - Senior (60 Years +) / Singles
CDSSAB - Foyer St. Laurent 374 McIntyre Street Apt. Details
CDSSAB - Foyer du Bonheur 375 McIntyre Street Apt. Details
Smooth Rock Falls - Senior (60 Years +)
Villa du Rocher 92 Ross Road Apt. Details
Timmins - Senior / Singles
CDSSAB - Bartleman Apts. 646 Bartleman Street Apt. Details
CDSSAB - Sterling Seniors 33 Sterling Avenue E. Apt. Details
CDSSAB - Melrose Apts. 491 Melrose Blvd. Apt. Details
City of Timmins Non Profit 77 Mountjoy Street N. Apt. Details
City of Timmins Non Profit 67 Mountjoy Street N. Apt. Details
CDSSAB - Pine Street N. Apts. 217 Pine Street North Apt. Details
Le Mirage, Foyer des Aînés 44 Borden Avenue Apt. Details
Timmins Finnish Seniors 231 Huot St., So. Porc. Apt. Details
CDSSAB - Park Ave. Apts. 620 Park Avenue * Walkup
Apt.
Details
CDSSAB - Lakeview Apts. 58 Lakeview, So. Porc. Apt. Details
CDSSAB - Lee Apts. 255 Lee Avenue Apt. Details
CDSSAB - College Apts. 615 College Street Apt. Details
Val Gagne - Senior (60 Years +)
CDSSAB - Foyer Immaculée Conception 590 Lessard Street * Walkup Details
 
Val Rita - Senior (60 Years +)
Villa Rita 24 Deschenaux St. Apt. Details
 
Hearst - Supportive Housing / Accessible Units
Maison Renaissance
Drug Abuse & Rehabilitation
924 Halle Street Res. Details
Maison Georgienne
Hearst Counselling Services
417 George Street * Walkup Details
Appartement Gamelin
Mentally Handicapped
44-46  13th Street Apt. Details
Maison Henri Lepan Supported Ind. Living
Mentally Handicapped
1114 Edward Street Apt. Details
Kapuskasing - Supportive Housing / Accessible Units
Kapuskasing Counselling 24 Ontario Street
7 Nelson
Apt. Details
Timmins - Supportive Housing / Accessible Units
Canadian Mental Health Assn. 239 Wilson AVe. House Details
Community Living Timmins 166-A Brousseau Ave. House Details
Cochrane Phase I - Urban Native Housing
Family / Singles 5th St., 5th Ave. Rural, Hough, 11th Ave., 7th St., 14th Ave. 15th Ave. House / Duplex / Semi Details
Cochrane Phase II - Urban Native Housing
Family / Singles 15th Ave. Semi Details
Cochrane Phase III - Urban Native Housing
Family / Singles Victoria St. / 15th Ave. Semi Details
Kapuskasing Phase II - Urban Native Housing
Family / Singles Lawrence / Hazel / Borden / Frontenac / Thompson / Egerton House / Row / Duplex Details
Hearst Phase II - Urban Native Housing
Family / Singles Prince St. Semi Details
Kapuskasing Phase III - Urban Native Housing
Family /  Singles Mill St. / Borden / Egerton / Frontenac / Winnipeg / Brunetville Semi Details
Smooth Rock Falls - Rural & Native Housing
Family / Singles Ross St. / Hollywood St. House Details
Val Rita - Rural & Native Housing
Family / Singles De La Coupe St. House Details
Ramore - Rural & Native Housing
Family / Singles Timmins / Ferguson / Bastien Streets House Details
Holtyre - Rural & Native Housing
Family / Singles Euclid / Edwards / Gleason Streets House Details
Matheson - Rural & Native Housing
Family / Singles Quinn St. House Details
Cochrane - Rural & Native Housing
Family / Singles Rural area (*2 units with garage) House Details
Fauquier - Rural & Native Housing
Family / Singles Belanger / Gauthier St. House Details
Frederick House - Rural & Native Housing
Family / Singles Rural area House Details
Mattice - Rural & Native Housing
Family / Singles Chabot / Aagnas Streets / Rural Area House Details
Moonbeam - Rural & Native Housing
Family / Singles Brunelle St. / Joseph St. House Details
Opasatika - Rural & Native Housing
Family / Singles Notre Dame / Govern't / St. Anne / St. Joseph House Details
 
I will send all supporting documents by:  Mail Fax
 
 
Copyright © Town of Hearst Non-Profit Corporation 2013