Rent Geared To Income - Birch Glen Co

Application for
Rent-Geared-to-Income (RGI)
Housing
If you do not complete all sections of this application form or
do not attach all the required documents, your application
cannot be processed.
Your completed application form and attached documents can be mailed or
delivered to:
Halton Access to Community Housing (HATCH)
690 Dorval Drive, 7th Floor
Oakville, ON L6K 3X9
APPLICATIONS WILL NOT BE ACCEPTED BY FAX
APPLICATIONS WILL NOT BE ACCEPTED BY FAX
For more information, Dial 311 or visit www.halton.ca/hatch or
email [email protected].
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Page 1 of 22
Application for Rent Geared-to-Income (RGI)
Housing
Use this checklist to make sure you have attached and/or prepared copies of all the required
documents to mail or deliver to HATCH for processing along with the completed Housing
Application form for Rent-Geared-to-Income (RGI) Housing.
Did you:
Complete all 9 sections of this application?
Sign page 22?
Complete the appropriate Building Selection Form (those 60 years of age or
older can select senior properties (Pages 15-20)?
Provide copies of Canadian birth certificates, Canadian passport, permanent
resident card or refugee claimant documents for ALL members of the household
(front and back)?
Provide a copy of the recent Notice of Assessment (NOA) for each household
member?
Attach confirmation that payments on arrears to a Social Housing Provider are in
good standing (Repayment Schedule)?
Are you requesting an additional bedroom for a member of your household where
there is a legal custody agreement or visiting rights involving overnight stays?
If yes, you must supply a copy of the agreement.
Additional requests (forms related to these requests are available online)
Are you requesting a wheelchair accessible unit?
Are you requesting an additional bedroom due to an existing medical condition?
Are you applying as a victim of domestic violence under the Provincial Special
Priority Policy?
Visit www.halton.ca/housing to print and complete the form(s) related to the additional
request you have selected above and provide to HATCH with your RGI housing
application.
IMPORTANT: If you do not complete all sections of this application form or do not attach
all the required documents your RGI Housing application cannot be processed.
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For Office Use Only
Confirmation #
• Please print clearly in black or blue ink.
• All sections must be completed in full.
• If your application is not completed in full, it will not be processed.
PWD Yes □ No
□
SECTION 1 – Your information
Primary Applicant
First name and middle initial
Gender
Date of Birth (MM/DD/YYYY)
Last name
Social Insurance Number Last name at birth
Marital status
Status in Canada
Address to receive mail
Apartment number
City
Street address
Province
Postal code
Calls to offer housing are normally made during the day. Please provide us with a daytime
number where you can be reached during the hours of 8:30 a.m. to 4:30 p.m., Monday to Friday.
Home telephone number
Work telephone number /
including extension
Your email address
Name
Cell phone number
Can we call you at
work?
Other person we can call if we cannot reach you
This person’s relationship to you Phone Number (s)
SECTION 1B – Second household member information
Secondary Applicant
First name and middle initial
Gender
Date of Birth (MM/DD/YYYY)
Last name
Social Insurance Number
Last name at birth
Marital status
Status in Canada
Apartment number
Current address
City
Province
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Postal Code
Page 4 of 22
• Please print clearly in black or blue ink.
• All sections must be completed in full.
• If your application is not completed in full, it will not be processed.
SECTION 2 – Who will live in the Rent Geared-to-Income (RGI) unit?
Relationship to
Primary
Applicant
Gender
Date of Birth
DD
M
F
M
F
M
F
M
F
M
F
MM
YYYY
Applied for Permanent Resident status
Last Name
Refugee or Refugee Claimant
First Name
Canadian Citizen
List any additional persons, who will be living in the RGI Unit.
Only the persons listed as members of this household can live in
the subsidized unit.
Permanent Resident or Landed
Immigrant
Status in Canada
Social Security
Number (SIN)
Do you share custody of the children listed on this application?
If so, please provide a copy of the custody agreement or legal document
outlining the details of your agreement (e.g., Affidavit).
SECTION 3 – Household Accommodation Requirements
Do you require a modified unit?
Do you or anyone who plans to live with you require support services in order to live
independently?
If you answer “Yes” to the above questions

V.4.0.01/16/2013
HATCH will mail you the appropriate forms to complete and
you must return to HATCH for processing.
Page 5 of 22
• Please print clearly in black or blue ink.
• All sections must be completed in full.
• If your application is not completed in full, it will not be processed.
SECTION 3 – Previous landlord and housing information
Current address
Address (Apt., Street, City)
Province
Postal Code
Rent
Own
Yes
No
Have you previously lived in a subsidized housing unit in Ontario?
IMPORTANT:
If you have arrears and owe money to a social housing provider you will not be eligible to be on
the HATCH centralized wait list. You must provide documentation to HATCH that you are in a repayment
program with the social housing provider you owe money to. The documentation must show that you are
regularly making payments before HATCH can process your application.
SECTION 4 – Additional Household Information
IMPORTANT: Please read and answer the following questions carefully
Are you pregnant?
Provide verification
i.e., a Doctor’s note;
Due date
(mm/dd/yyyy): ______________
Do you or anyone on this application own
property in Canada or any other country?
* Once you are in receipt of RGI
assistance, owned property would have to
be sold within 60 days of being housed
Are you or any other person on this
application form under an enforceable
removal order?
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__
Other country: ____________
Name of household member:
______________________
Page 6 of 22
• Please print clearly in black or blue ink.
• All sections must be completed in full.
• If your application is not completed in full, it will not be processed.
SECTION 5 – Special household considerations
Newcomer Status
Are you and the other member(s) of your household newcomers to Canada who
arrived less than one year ago?
● If you answer “Yes”, please include:
A copy of Immigration Documents with the date of entry in Canada
Please see SECTION 7: Status in Canada Documentation on page 8.
Homeless Status
Could any member of your household be considered homeless?
Where are you currently living? (Please provide a brief description of your circumstances below)
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_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Please use the back of this page if more space is required
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• Please print clearly in black or blue ink.
• All sections must be completed in full.
• If your application is not completed in full, it will not be processed.
SECTION 6 – Special household considerations
Special Priority Policy (SPP) Status
Are you applying as a victim of domestic abuse under the Provincial
Special Priority Policy (SPP)?
● If you answer “Yes”,
HATCH will contact you about your application.
For Office Use Only
VoDV: Y
□
N
□
IMPORTANT:
For your own safety it is important that we send the SPP Request Package to a safe mailing
address. Please let us know what address we can send correspondence to by filling in
Section 1 on Page 4 of this application form.
SECTION 7 – Eligibility information required
Status in Canada Documentation
IMPORTANT: Please provide a copy of one of the following documents for each household
member
Birth Certificate (front and back)
OR
A copy of Immigration Documents (Please review the options below)
Canadian Citizenship Documents (front and back)
Permanent Resident Card (front and back)
Refugee Claimant Documents (front and back)
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Page 8 of 22
• Please print clearly in black or blue ink.
• All sections must be completed in full.
• If your application is not completed in full, it will not be processed.
SECTION 8 : Eligibility information required (Continued)
Notice Of Assessment (NOA) (provide a copy of ALL the pages of your most recent NOA)
What is a Notice of Assessment (NOA)?
Each year taxpayers complete a tax return based on their previous years income to send to Canada Revenue
Agency (CRA). The CRA issue a Notice of Assessment (NOA) to taxpayers upon receipt of this tax return.
The NOA is an annual statement sent by revenue authorities to taxpayers detailing the amount of income
tax they owe, tax refund, tax credit, total income for previous year and income tax already paid. HATCH is
requesting a copy of the NOA you received from your most recent tax return. Please send a copy of ALL
the pages of your most recent NOA.
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SECTION 9 – BUILDING SELECTIONS: Rent-Geared-to-Income (RGI) for singles, couples and
aged 65+
All-age buildings may be selected by any applicant no matter their age. If you are 60+ and wish to apply for
building selections for seniors please go to page 15 of this application form. Seniors may wish to apply for
all-age and Senior building selections. However, if you are younger than 60+ you are only eligible to select
all-age buildings.
Legend:
All-Age
Community
Address
Area
Bldg
Type
# of
RGI
units
ACTON
apartment
townhouse
utilities excluded
good amount of parking spaces
one - two bedroom wheelchair
accessible unit.
unit sizes
1-BR
2-BR
3-BR
Cobblehill
Homes
Co-op
53 Cook
Street
Apt.
15
√
√
Cobblehill
Homes
Co-op
53 Cook
Street
TH
10
√
√
Braeside
46
Holmesway
Place
Apt.
12
10 – 44
Holmesway
Place
TH
18
Holmesway
Place
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√
Incl.
Good
Excl.
Good
Incl.
LTD
Incl.
Good
4-BR
√
√
√
Parking
= wheelchair accessible units (WCA)
Apt. =
TH =
Excl. =
Good =
1-2BR =
Utilities
Co-op = Cooperative
Incl. = utilities included
LTD = limited Parking spaces
√
1-2BR
1-3BR
Page 10 of 22
Area
MILTON
unit sizes
1-BR
Rotary
Square
154 Bronte
Street, S.
Rotary
Square
154
Bronte
Street, S.
Harmony
Court
111 Ontario
St. N
South
North
Apt.
11
TH
9
Apt.
36
BURLINGTON
2-BR
3-BR
√
√
1-BR
2-BR
3-BR
Incl.
LTD
1-2BR
Incl.
Good
1-1BR
4-BR
√
√
Parking
Address
Bldg
Type
Utilities
All-Age
Community
# of
RGI
units
Excl.
4-BR
Walkers
Fields
2300
Walkers
Line
North
TH
32
√
√
Excl.
Good
2-2BR
The Manor
2039
Walkers
Line
North
TH
84
√
√
Excl.
Good
6-3BR
Driftwood
Drive
3030
Driftwood
Drive
North
TH
44
√
√
Excl.
Good
1-2BR
1-3BR
Tansley
Park
4090
Millcroft
Park Dr
North
TH
12
√
√
Excl.
Good
1-2BR
Van
Norman
Place
1380
Guelph Line
North
TH
40
√
√
Hydro
incl.
Good
Van
Norman
Place
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1380
Guelph Line
North
Apt.
14
√
√
4-1BR
Page 11 of 22
Area
BURLINGTON Cont…
Victoria
Village
2461
Whittaker
Drive
Don
Quixote
Co-op
Parking
Address
Bldg
Type
Utilities
All-Age
Community
# of
RGI
units
Excl.
Good
√
Excl.
Good
1-2BR
1-3BR
√
Excl.
Good
2-2BR
Excl.
Good
6-3BR
√
Incl.
LTD
√
Incl.
Good
Incl.
LTD
Excl.
Good
Incl.
Good
unit sizes
1-BR
2-BR
3-BR
√
North
TH
24
1315 Maple
Crossing
Blvd.
SW
TH
41
√
√
Maple
Crossing
1300 Maple
Crossing
Blvd.
SW
TH
60
√
√
Nelson
Co-op
28A-1026
Glendor
Avenue
SW
TH
90
√
√
Brant Court
Apts.
708-710
Brant Street
SW
Apt.
16
STOA
Co-op
456 Brock
Ave.
SW
Apt.
49
Burloak
Drive
254 – 360
Burloak
Drive
SE
TH
Walkers
Landing
515 Walkers
Line
SE
TH
√
√
54
√
√
46
√
√
2-BR
3-BR
4-BR
√
√
√
OAKVILLE
Elm Road
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1-BR
1478 - 1494
Elm Road
NE
TH
4-BR
54
√
3-1BR
3-2BR
2-3BR
Page 12 of 22
Area
OAKVILLE Cont…
1531 Sixth
Line
NE
TH
27
Golden
Briar
Heights
2250
Golden
Briar Trail
NE
TH
77
Interfaith
Homes
Rimmington
Drive
TH
NW
Apt.
29
Birch Glen
Co-op
1160 Dorval
Drive
NW
Apt.
101
Glen Oaks
Co-op
1180 Dorval
Drive
NW
Apt.
84
Brays Lane
2299 Bray's
Lane
NW
TH
49
1220
Glen Valley
Rd
NW
TH
45
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Good
2-3BR
Excl.
Good
1-3BR
√
Incl.
Good
2-2BR
√
Incl.
Good
6-1BR
6-2BR
1-3BR
Incl.
Good
5-1BR
7-2BR
1-3BR
Excl.
LTD
2-2BR
Excl.
Good
2-2BR
Incl.
Good
4-1BR
2-2BR
1-3BR
Incl.
LTD
√
√
√
√
√
1150 Dorval
Drive
Margaret
Drive
Excl.
4-BR
57
The
Abbeyview
The
Oaklands
1-2BR
3-BR
Various Units
Glen Valley
Place
LTD
2-BR
√
NW
Excl.
unit sizes
1-BR
Donaghey
Square
Parking
Address
Bldg
Type
Utilities
All-Age
Community
# of
RGI
units
√
√
√
√
√
√
√
√
√
2021
Merchants
Gate
NW
287 - 359
Margaret
Drive
SW
Apt.
√
88
√
TH
√
√
√
48
√
√
√
Page 13 of 22
Area
OAKVILLE Cont…
Maurice
Drive
1-BR
284 - 320
Maurice
Drive
SW
284 - 320
Maurice
Drive
SW
Prince
Charles
Place
111
Prince
Charles Dr.
SW
Sheridan
Woods
2301
Sheridan
Garden Dr.
SE
Mariposa
Co-op
1150 Gable
Drive
SE
TH
23
Jean &
Howard
Caine Apts.
259
Robinson
Street
SE
Apt.
59
Maurice
Drive
unit sizes
Apt.
2-BR
3-BR
Parking
Address
Bldg
Type
Utilities
All-Age
Community
# of
RGI
units
Incl.
LTD
Incl.
LTD
Incl.
Good
4-2BR
Excl.
Good
1-2BR
Excl.
Good
Incl.
Good
4-BR
16
√
TH
44
√
Apt.
43
√
TH
√
√
35
√
√
√
√
√
√
*All
units
* Priority will be given to applicants who require a modified unit due to a physical disability.
Various rent supplement locations will be available to all applicants.
Refusing a unit offer from the Rent Supplement Program will not count as a refusal on your HATCH
application.
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Page 14 of 22
Community
You must be 60+
to select the
building options
below
Address
# of
RGI
units
ACTON
unit sizes
1-BR
Applying for Supportive housing is
possible
Senior
Parking space availability
Place check mark to select
SENIOR BUILDING SELECTIONS (pages 15-20)
Other
remarks
2-BR

Lakeview Villa
17 Elizabeth
Drive
52
GEORGETOWN
Kin Court
Cote Terrace
Seniors Apts.
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3 Hyde Park
Drive
171 Main
Street South
24
40
YES
YES
1-BR
2-BR
YES
NO
YES
NO
LTD
YES
3-1BR
Good
NO
-
Good
NO

12 units
are
supportive
housing.
Eligible
age for
supportive
housing is
60+.
The
available
2-1BR
2-BR units
and
are for
2-2BR
wheelchair
users only.
Page 15 of 22
Community
You must be 60+
to select the
building options
below
Sargent Court
Address
11 Sargent
Road
# of
RGI
units
38
GEORGETOWN Cont…
unit sizes
YES
NO
1-BR
2-BR
LTD
Applying for Supportive housing is
possible
Senior
Parking space availability
Place check mark to select
SENIOR BUILDING SELECTIONS (pages 15-20)
NO
Other
remarks
-

John Armstrong
Terrace
8 Durham
Street
89
MILTON
YES
NO
1-BR
2-BR
LTD
YES
-


The Bruce Apts.
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40 Ontario
Street S.
88
YES
YES
LTD
YES
1-2BR

39 units
are
supportive
housing.
Eligible
age for
supportive
housing is
60+.
15-20
units are
supportive
housing.
Eligible
age for
supportive
housing is
60+
Page 16 of 22
Community
You must be 60+
to select the
building options
below
Martin House
Seniors
Residence
Address
189 Ontario
Street South
# of
RGI
units
80
BURLINGTON – SOUTH WEST
unit sizes
YES
YES
1-BR
2-BR
Applying for Supportive housing is
possible
Senior
Parking space availability
Place check mark to select
SENIOR BUILDING SELECTIONS (pages 15-20)
Good
NO
8-1BR
NO
3-1BR
St. Luke’s Close
1421 Elgin
Street
36
YES
NO
LTD
Woodward Park
2424
Woodward
Avenue
93
YES
NO
LTD
NO

Aldershot Village 540 Plains
Road East
Residence
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55
YES
YES
Other
remarks
LTD
The project includes 10
wheelchair accessible 1-BR
units with support services.
To apply for those units
contact Cheshire
Independent Living
Services at 905-634-6677.
Eligible age is 65+.
Page 17 of 22
Community
You must be 60+
to select the
building options
below
Address
# of
RGI
units
unit sizes
Applying for Supportive housing is
possible
Senior
Parking space availability
Place check mark to select
SENIOR BUILDING SELECTIONS (pages 15-20)
Other
remarks

Wellington
Terrace
410 John
Street
75
YES
YES
Good
YES
221BR

7-2BR
BURLINGTON – NORTH of the
QEW
Palmer Place
3097 Palmer
Drive
1-BR
39
BURLINGTON – SOUTH EAST
2-BR
YES
NO
1-BR
2-BR
Good
YES
All-Age
Supportive
3-1BR
Housing
units - 12
Walkers Landing
(seniors)
513 Walkers
Line
41
YES
NO
Good
NO
3-1BR
Longmoor Drive
4100
Longmoor Dr
109
YES
NO
LTD
NO
-
V.4.0.01/16/2013
40 units
are
supportive
housing.
Eligible
age for
supportive
housing is
60+.
Page 18 of 22
Community
You must be 60+
to select the
building options
below
Pinedale Avenue
Address
5250 Pinedale
Ave
# of
RGI
units
141
OAKVILLE – SOUTH WEST
Oakville Senior
Citizens
Residence
Oakville Senior
Citizens
Residence
unit sizes
YES
NO
1-BR
2-BR
LTD
Applying for Supportive housing is
possible
Senior
Parking space availability
Place check mark to select
SENIOR BUILDING SELECTIONS (pages 15-20)
Other
remarks
NO
2220
Lakeshore
Road West
(Apartment
Tower)
164
YES
NO
LTD
YES
2222
Lakeshore
Road West
(Residential
Tower)
172
Bed-sitting
rooms
LTD
YES
-




10 units are
supportive housing.
Eligible age for
supportive housing
is 65+.
All units are
supportive housing.
Eligible age is 65+.

John R. Rhodes
Residence
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271 Kerr Street
241
YES
YES
LTD
YES
7-1BR

20 units
are
supportive
housing
Eligible
age for
supportive
housing is
60+.
Page 19 of 22
Community
You must be 60+
to select the
building options
below
Address
# of
RGI
units
OAKVILLE – NORTH EAST
Knox Heritage
Place
2191 Sixth
Line
22
unit sizes
1-BR
2-BR
YES
NO
Good
Applying for Supportive housing is
possible
Senior
Parking space availability
Place check mark to select
SENIOR BUILDING SELECTIONS (pages 15-20)
NO
Other
remarks
-
Various Rent Supplement locations will be available to all applicants:
Refusing a unit offer from the Rent Supplement Program will not count as a refusal on your HATCH application.
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Page 20 of 22
SECTION 9 – Release and consent
Please do not send this form to Halton Region without all required signatures
Please read this release and content section carefully, and sign in 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 this.
1. I understand that Halton Region 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 (RGI) and/or Special Needs Housing. Any questions about the
collection of my personal information should be directed to the Manager, Housing Services, 690
Dorval Drive, 7th Floor, Oakville ON L6K 3X9, 905 825-6000, or toll free 1-866-442-5866, TTY
905 827-9833.
2. I understand and agree that Halton Region will use the information I give them for the following
specific purposes:
 to find out if I qualify for the housing I have applied for
 to find out if I continue to qualify for rent-geared-to-income assistance and/or special needs
housing,
 to find out how much assistance I am eligible for
 for statistical reporting and policy research
3. I consent to the release of any information to Halton Region about any bank account, safety deposit
box, assets of any nature or kind held by me, or on my behalf, or by or on behalf of any of my
dependants 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 allow Halton Region and the housing providers to whom
I will be applying to obtain any credit information about me from any credit agency or any other
source.
5. I allow Halton Region and the housing providers to whom I will be applying to share my personal
information, without further notice to me, with the Ministry of Municipal Affairs and Housing, the
Social Housing Services Corporation, other municipal service managers or district social services
administration boards or lead agencies as defined under the Housing Services Act (HSA), 2011 and
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 Day Nurseries Act, 1990.
6. I consent to Halton Region giving my personal information to the government of enforcing the
Income Tax Act (Canada), 1985 or the Immigration and Refugee Protection Act (IRPA), 2002.
7. I understand that any of my personal information given by Halton Region to a government or body
mentioned above in paragraph 5 and 6 will only be given in accordance with the Housing Services
Act, 2011 and its regulations.
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Page 21 of 22
8. I understand and agree that Halton Region may cross-reference my personal information related to
this housing application with other municipal data pertaining to my household.
9. I understand that any inquiries with respect to my personal information may take the form of
electronic data exchanges.
10. I understand that all information I give to Halton Region will belong to them and that they will
give my information to the housing providers I will apply to.
11. I understand that only the people I have listed on this application form may live with me in Rent
Geared-to-Income (RGI) housing.
12. I understand that Halton Region and/or the housing provider I will apply to will use my personal
information to determine if I am eligible or continue to be eligible for RGI assistance and/or Special
Needs housing; the size and type of unit I may be eligible to receive; my placement on waiting lists;
and the amount of geared-to-income-rent payable by me.
13. I declare that I am in Canada legally.
14. I understand that I must pay back or arrange to pay any money I may owe to any subsidized
housing project before I can be offered a subsidized unit.
15. I understand that it is 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 and offence carries up to a $5,000 fine or to up to
six months imprisonment as well as a prohibition from re-applying for assistance for a minimum
period of two years. If something on this application is missing, incorrect or false, Halton Region or
the housing providers I have applied to may request additional information or may cancel my
application.
16. I understand that if Halton Region and/or the Housing Providers representing Halton Region
request a household to reimburse Halton Region, 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 Halton Region.
All people on this application who are 16 years of age and older who are not full-time students
must sign below to indicate they have read and accept all terms and conditions of SECTION 9 –
Release and consent. Please do not send this form to Halton Region without all required
signatures
Household member
(Please print name)
Signature
Date signed
1
2
3
4
V.4.0.01/16/2013
Page 22 of 22

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