Application Form for MARKET RENT Housing

Note: All applicants applying for housing with the Hellenic Home for the Aged Inc., must be 59 years of age or older and must be of Greek descent.

HELLENIC HOME DISCLOSURE

The Hellenic Home for the Aged Inc. will ensure that all applicants to the Hellenic Home for the Aged Inc. will be treated in a fair, consistent and accurate manner. The Hellenic Home for the Aged Inc. will further ensure that all personal information remains confidential.

APPLICANT #1 INFORMATION

First Name:

Family Name:

Apartment#:

Street Address:

City:

Province:

Postal Code:

Telephone:

Are you a Canadian citizen?

Are you a Landed Immigrant? Yes No

CO-APPLICANT #2 INFORMATION

First Name:

Family Name:

Apartment#:

Street Address:

City:

Province:

Postal Code:

Telephone:

Are you a Canadian citizen?

Are you a Landed Immigrant? Yes No

Number of bedrooms applying for: One Bedroom Two Bedroom

Is parking required: Yes No

HOUSEHOLD INFORMATION

Name

Relationship To You

Date of Birth

Day

Month

Year

SEX
M/F

Ontario Health Card Number

INCOME INFORMATION

– List all monies being received by you and all persons who will be living with you. Please see “Instruction Page” for examples of types of income. Use extra paper, if needed.

NAME	Applicant #1	Applicant # 2	GROSS INCOME PER MONTH $
Canada Pension Plan
Old Age Security
Supplement
Retirement Pension
Employment Income
Disability Allowance
Other
Grand Total

ASSETS INFORMATION

– – List all assets owned by you and all persons who will be living with you. Please see “Instruction Page” for examples of types of assets. Use extra paper if needed.

TYPE OF ASSET	Applicant #1	Applicant # 2	VALUE $



Grand Total

Bank Name:

Branch #:

Phone:

SPECIAL NEEDS

Does any member of your household have “Special Needs” that require the following?

Medical Problems: Any medical condition(s) that you feel we should be aware of, that may impede your abilities to perform your daily living activities, please explain:

Wheelchair Accessible Unit

Any modifications required to Unit? Please Explain:

MANAGING DAILY

People in this building are supposed to be able to live independently with or without external supports. Do you believe that you and your co-applicant can live independently?

Yes No (If NO please explain why)

CONTACT INFORMATION

Please list a person we can contact on your behalf

Name of Contact:

Relationship to You?

Address:

Telephone (home):

Telephone (work):

Telephone (cell):

Telephone (pager):

HOUSING HISTORY

– List all previous addresses for the past 5 years.

Apt.#

Street Address:

City:

Landlord’s Name:

Landlord’s Address:

Date you moved in:

Date you moved out:

Why did you move out?

Preplanning

– List all previous addresses for the past 5 years.

Do You Have a Will? Yes No

Do you have an Advanced Directive (Do Not Resuscitate Orders)? Yes No

Have you established a Power of Attorney?

For Personal Care? Yes No

For Finance? Yes No

Subject to the other terms of this application, the above information is strictly confidential and will not be released by us except where such information is to be relied upon by us in any legal proceedings, or must otherwise be produced in accordance with relevant law.

Applicant’s Acknowledgement

The undersigned acknowledges that Hellenic Home for the Aged Inc. apartment units are not a nursing home and that to be accepted as a tenant and to remain a tenant the undersigned must be able to either (a) manage on her/his own and be in good health or (b) make arrangements satisfactory to Hellenic Home for the Aged Inc. to receive all appropriate support services from a service agency in the community. Tenants are responsible to care for her/his personal needs, and if the time should come that any tenant (a) is not able to care for her/his personal needs or (b) has not made arrangements satisfactory to Hellenic Home for the Aged Inc. to receive all appropriate support services from a service agency in the community, then it shall be necessary for such tenant to find accommodation elsewhere and vacate the premises.

Information Consent

The undersigned consents to Hellenic Home for the Aged Inc., obtaining such information as may be deemed necessary at any time in connection with the undersigned in respect of her/his application for the above premises being applied for herein and for any renewal or extension thereof. The undersigned also consents to the disclosure of any information concerning the undersigned and the sharing or exchange of information concerning the undersigned, with and to (a) any credit reporting agency or to any person to whom the undersigned has or proposed to have financial relations and to Hellenic Home for the Aged Inc. obtaining a credit report concerning the undersigned and/or (b) any physician or other health care professional.The undersigned agrees to provide to Hellenic Home for the Aged Inc. satisfactory evidence of age, health, income and Canadian Residency.

Date

In accordance with s.99(3) of the Social Housing Reform Act, 2000, 11 and 39 Winona Drive’s mandate is to serve Seniors of Greek Origin. This agreement is fully recognized by the City of Toronto and administration and operations will be consistent with the mandate.

With your application please ensure you have enclosed a copy of any one of the following documents:

Greek Passport
Birth Certificate
Permanent Resident Status (Taftotita)

A $30.00 nonrefundable deposit is required for administration costs. Please enter your credit card information below.

Credit Card Information

Card Holder Name

Credit Card Number

Expired Month:

Expired Years:

CVV Number:

Instruction Page

Income information

Report all of the gross monthly income (before deductions) and estimated value of assets owned for each member of your household. You do not have to attach proof with this application, but it will be required later.

Assets Information

Types of Assets include any savings, investments or property that you own such as:

Application Form for MARKET RENT Housing

HELLENIC HOME DISCLOSURE

APPLICANT #1 INFORMATION

CO-APPLICANT #2 INFORMATION

HOUSEHOLD INFORMATION

INCOME INFORMATION

ASSETS INFORMATION

SPECIAL NEEDS

MANAGING DAILY

ESSENTIAL DAY-TO-DAY ACTIVITIES

APPLICANT #1

APPLICANT #2 (co-applicant)

CONTACT INFORMATION

HOUSING HISTORY

Preplanning

Applicant’s Acknowledgement

Information Consent

Credit Card Information

Instruction Page

Income information

Assets Information