Notice of Change Form

Birch Glen Co-operative Homes Inc.
Notice of Change Form

    e.g. lost a job, started a new job, got a raise, etc.

    e.g. bought or sold land, cottage, RRSP, etc.

    e.g. someone moved in or out, guests, etc.

    e.g. deportation or departure order, etc.

    e.g. no longer full-time student

    Release and Consent

    1. I understand that Halton Region and Birch Glen on behalf of Halton Region are authorized to collect personal information about me in accordance with the Housing Services Act, 2011. Any questions about the collection of my personal information should be directed to: Manager, Housing Initiatives and Administration, Housing Division, Regional Municipality of Halton (telephone: (905) 825-6000, 1-866-442-5866, TTY (905) 827-9833).
    2. I understand and agree that Halton Region and Birch Glen, on behalf of Halton Region will use the information I give them:
      • to find out if I qualify for the housing I have applied for,
      • to find out if I continue to qualify for rent-geared-income assistance and/or special needs housing, and
      • to find out how much assistance I am eligible for.
    3. I consent to Halton Region and Birch Glen, on behalf of Halton Region giving the information on this form, and any attachments, to the social services offices, other municipal service managers or district social services administration boards and housing providers without further notice to me. I understand that this will be done if the information is necessary to make decisions or verify my eligibility for assistance under:
      • the Housing Services Act, 2011
      • the Ontario Works Act, 1997
      • the Ontario Disability Support Program Act, 1997
      • the Day Nurseries Act.
    4. I consent to the release of any information to Halton Region and Birch Glen, on behalf of 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 dependents or children temporarily in my care, alone or jointly with any other person in any financial institution.
    5. I consent to Halton Region and Birch Glen, on behalf of Halton Region giving the information on this form and any attachments to the government of Canada, a department, ministry, or agency of it, without further notice to me, if the information is necessary for the purpose of administering or enforcing the Income Tax Act (Canada) or the Immigration Act.
    6. I consent to Halton Region and Birch Glen, on behalf of Halton Region giving the information on this form and any attachments to any government or agency or individual with whom Halton Region has made an agreement under the Housing Services Act, 2011, without further notice to me, for the purpose of conducting research related to a social benefit program or social housing or rent-to-geared-to-income assistance program.
    7. I understand that any information on this document and any attachment given by Halton Region to a body listed above is confidential and will only be given in accordance with the Housing Services Act, 2011.
    8. I understand and agree that Halton Region and Birch Glen, on behalf of Halton Region can receive, through its employees or agents, credit information from any credit agency or any other source.

    Declaration

    1. I declare that everything I have written in this document is true and that no information that is required to be given has been withheld or omitted.
    2. I understand that all information I give to Halton Region and Birch Glen, on behalf of Halton Region will belong to them and they will give my information to the housing providers I have chosen.
    3. I understand that only the people I have listed on this document may live with me in subsidized housing.
    4. I understand that Halton Region and Birch Glen, on behalf of Halton Region will use the information I give them:
      • to find out if I qualify for the housing I have applied for,
      • to find out if I continue to qualify for rent-geared-income assistance and/or special needs housing, and
      • to find out how much assistance I am eligible for.
    5. I declare that I am in Canada legally.
    6. I understand that I must pay back or arrange to pay any money I may owe to any subsidized housing project.
    7. I understand that it is an offence, under the Housing Services Act, 2011, for an individual to knowingly obtain or assist a household member to obtain rent geared to income assistance for which they are not entitled. Such an offence carries up to a $5,000 fine or to up to 6 months imprisonment as well as a prohibition from re-applying for assistance for a minimum period of two years. If something on this document is missing, incorrect or false, Halton Region and Birch Glen, on behalf of Halton Region may request additional information or may cancel my eligibility for subsidy or special needs housing.