Rent-Geared-To-Income (RGI) Assistance Annual Review Form

Please read carefully before continuing:

• The personal information requested on this form will be used to calculate your RGI rent and review your continued eligibility for subsidized housing in accordance with the Housing Services Act, 2011, associated regulations and City of Brantford Local Rules.
• Please read each section carefully and attach all documents requested.

Your Unit Information

Household members – who lives with you?

• List the names of everyone that lives with you.
• Status in Canada options: Canadian citizen, permanent resident, convention refugee, refugee claimant

Household income

• In this section, list all household members 16 years of age and older.
• If you are 16 years and older and are attending school full-time in a recognized Educational Institution, confirmation of full-time student status is required. For a list of recognized Educational Institutions in Ontario, please visit the Government of Canada website.
• If you are 16 years and older and are not attending school full-time in a recognized Educational Institution, your Notice of Assessment is required.
• If in receipt of Ontario Works of Ontario Disability Support Program, your most recent copy of the Benefit statement is required

Tenant Insurance

• If insurance is required as per your lease, you must attach a copy of your Certificate of Insurance as required by the conditions of your lease or the co-op’s by-laws.

Emergency Contact

• List the name and contact information for an individual we can contact in case of an emergency (preferably a person who does not reside with you).

Consent and Declaration

All household members who are 16+ must read and agree to consent.

By signing this statement, I confirm the following:

1. All the information provided in this Income & Assets Verification Form for Rent-Geared-to-Income Assistance is true and complete to the best of my knowledge. I have not knowingly left out any information or provided false information.
2. I understand that providing false information or withholding information from a housing provider for the City of Brantford may result in the loss of my rent-geared-to-income subsidy.
3. I understand that I must inform my housing provider for the City of Brantford within 30 days of any change in my income or assets, my right to stay in Canada, and if there is a change in the household members residing in my unit.
4. I understand that my housing provider for the City of Brantford will use my personal information, and the information provided during this review to determine my ongoing eligibility for rent-geared-to-income assistance, to determine the size and type of unit I may be eligible for and determine the amount of rent- geared-to income rent payable by me.
5. I agree to allow my housing provider for the City of Brantford to make inquiries to verify the information I have provided in this Annual Review Form, without further notice to me, to outside organizations and entities which could include the following: Ministry of Municipal Affairs and Housing, the Housing Service Corporation, other municipal Service Managers or District Social Services Administration Boards or lead agencies as defined under the Act, if it is required to determine eligibility for assistance under the Ontario Works Act 1997, the Ontario Disability Support Program Act, 1997 or the Day Nurseries Act. I permit any person, corporation, or social agency to release any required information.
6. I understand that the housing provider for the City of Brantford does not have to notify me before releasing information on this form and/or any attached documents to any government or organization with which the City of Brantford may share information under the Housing Services Act, 2011 (HSA).
7. I understand that any inquiries with respect to my personal information may take the form of electronic data exchanges.
8. I understand that any information on this form and/or any attached documents will only be released in accordance with the HSA, the Municipal Freedom of Information and Protection of Privacy Act and associated regulations.

All members of the household over 16 years of age have read, understood and accepted the above.