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Request for an Internal Review Under the Housing Services Act

Requests for an internal review should be made in writing within 10 business days of the household receiving the notice of the decision.

If you need legal advice you may contact the Community Legal Clinic – Brant, Haldimand, Norfolk at 1100 Clarence Street South, Suite #203, Brantford, Ontario, 519-752-8669.

First name

Last name

Street number

Street name

Unit number

City

Postal code

Phone number

Date decision received

Email address

Re-enter email address

Why do you want to appeal?

I was denied Rent-Geared-to-Income subsidy

I disagree with the amount of Rent-Geared-to-Income I must pay

I was denied Special Priority, or Homeless status

I was refused a unit

I was denied a modified unit

I disagree with the size of unit I qualify for

I would like to have this decision reviewed because:

The Applicant(s) have read, understood and agree to the Terms of the agreement

By checking this box, I agree to the Terms of the Housing and Homelessness Department request for an Internal Review Under the Housing Services Act.

Applicant consent

By checking this box, I hereby request for an Internal Review Under the Housing Services Act and authorize and consent to the completion of this form and its submission to the City of Brantford Housing Services Department and to the disclosure to the City of Brantford of any additional information it may request to clarify the information on this form.

Personal information contained in this form or in any attachments is collected by the City of Brantford, pursuant to the Housing Services Act, 2011, Freedom of Information and Protection of Privacy Act or the Municipal Freedom of Information and Protection of Privacy Act and will be used for the purposes of an internal review and/or making eligibility decisions for housing assistance and/or social assistance subsidies. I/We consent to the ongoing use and disclosure of my/our personal information as described above for the purposes of social housing and/or social assistance support decisions as may be necessary. Further, I/We acknowledge I/We have read and understand this consent.