Required fields are marked with asterisks (*)

County of Renfrew – Community Services Department

Homelessness Prevention Program (HPP) Application

Applicant name and contact information:

First Name

Last Name

Phone Number

Email Address

Please provide your date of birth below. (month, day & year)

Street Address

City

A co-applicant must also complete this application if shelter expenses are shared:

Co-Applicant Name

Phone Number

Date of Birth

Email Address

Names of family, friends, or roommates that live with you:

Name

Date of Birth

Relationship

Monthly Household Income (for all household members 18 years of age or older):

Type of Income

Amount

Type of Income

Amount

Type of Income

Amount

Current Monthly Household Expenses:

(Where you currently reside)

Mortgage + Property Tax

Rent

Hydro

Water

Tenant or Homeowner’s Insurance

Fuel (gas, oil, propane, wood)

Please let us know the reason for your application:

I/We affirm that the information provided within this application is true.
I/We understand that approval or payment of funds is not guaranteed.
I/We agree to make a payment arrangement with the service provider (utility company or landlord), should my/our expenses exceed what is approved by the Homelessness Prevention Program.
I/We agree to direct payment arrangement from my OW/ODSP (if applicable).
I/we understand that failure to pay the service provider as agreed, may result in the disconnection of the utility and/or eviction and that I may not be eligible for further assistance from the Homelessness Prevention Program.
I/We consent to the disclosure/release of personal information to an authorized representative of the County of Renfrew Community Services Department for the purpose of determining or verifying eligibility for financial assistance from the Homelessness Prevention Program.
I/We further consent specifically to the exchange of information between the County of Renfrew Community Services Department and any utility company, landlord, municipality, social services program, Ontario Works, Ontario Disability Support Program (including access to electronic data) or other person or business whatsoever that is necessary to determine whether I/we are eligible for assistance from the Homelessness Prevention Program.
I/We have read or have had this document read to me/us and understand the terms of the Application. Agreement and Consent and Disclosure/Release of Information set out above.
I/We are at least 18 years of age.
I/We agree that this application/consent is valid for one year

Please sign

Clear