Request for Transfer

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Fax / télécopieur: (519) 679-7000

Telephone / téléphone: (519) 434-2765 379 Dundas Street, Suite 207, London, Ontario N6B 1V5

379 rue Dundas, bureau 207, London, Ontario N6B 1V5 www.london-housing.ca

Request for Transfer

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2. A completed Declaration and Consent to Disclosure section Your completed transfer application must include:

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1. A completed Applicant Information section

Application Checklist

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Information for applicants

 By completing this transfer application form you are indicating that you

wish to apply for a transfer to another LMHC unit or property.

 In order to avoid any delays in processing your transfer request, please

ensure that all sections of the application are completed.

 All information disclosed to LMHC will remain con idential.

 If you apply for a transfer and it is determined that you have deliberately

provided false or inaccurate information, your transfer will be denied.

Why do you wish to transfer from your current unit?

Immediate transfer (Special Priority Policy, SPP)

Underhoused

Overhoused

LMHC is currently only transferring tenants for legislative reasons (Special Priority Policy, SPP), underhoused or overhoused. Please contact your CRW to complete this form.

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Yes No Yes No

First name and middle initial Date of birth (mm/dd/yyyy)

Gender Social Insurance Number

Home phone Work phone

Can we call you at home? Can we call you at work?

Cell phone E‐mail address

Current address

Current unit size

Would like to transfer to

Name of household member requesting transfer (if different from above)

Bachelor 1Bedrm 2Bedrm 3Bedrm 4Bedrm 5Bedrm

1 2 3 4 5 6

Iwanttorelocateto:

Male Female

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Last na me First na me an d middl e initi al Date of birth Gender SIN Re lati onshi p to yo 1 2 3 4 5 6 7 8 9 10 Li st all th e people (ot her th an you rs elf ) wh o curr ent ly live in you r home. Li st all inc ome for you or th e fa mily me mb er s list ed abo ve. Family memb er wi th inco me Typ e of inco me rec eived Gross mon thly income 1 2 3 4

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undertheageof16orisunableforanyreasontosigntheconsentortogiveavalidconsent,

theconsentmaybesignedontheperson’sbehalfbytheparentorguardian;anattorney

underapowerofattorneythatauthorizesthatattorneytogivetheconsentontheperson’s

behalf;orapersonwhoisotherwiseauthorizedtogivetheconsentontheperson’sbehalf.

I, ______________________________________________ , hereby authorize and consent to the disclosure to London and Middlesex Housing Corporation of information and documents required by London and Middlesex Housing Corporation for the purpose of verifying the statements on this form and assessing my

eligibility for a transfer.

_________________________________________________ __________________________________

Signature of applicant (or person authorized to sign on their behalf) Date signed

Alltenantsovertheageof16livinginthisunitmustalsosignthistransferrequest.

_________________________________________________ __________________________________

Signature of tenant #2 Date signed

_________________________________________________ __________________________________

Personal information contained on this form or in attachments is collected pursuant to the SocialHousingReformAct,2000,Sections 162,163,164and165 or the MunicipalFreedomandProtectionofPrivacyAct,(R.S.O.1990,cM.56). This information will be used to determine suitability and eligibility for housing applied to, continuation of housing and/or transfer of housing within the London and Middlesex Housing Corporation.

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Instructions for Professionals

Theapplicantisapplyingforanimmediatetransfer. In order for the

London and Middlesex Housing Corporation to determine the applicant’s eligibility we will need the following documents from you.

1. CompletetheProfessional’s Verification and Declaration

sectionofthisform.

2. AttachaLetter of Verification outliningthenatureofthe

applicant’ssituationandremediesthathavebeenattemptedto

resolvethesituation.(You may refer to the indicators of violence/abuse/

criminal activity on page 4 of this form if you need assistance in writing your letter.)

3. AttachallapplicableSupporting Documentation.

You may give this form directly to the applicant, or mail it to the address at the bottom of this form. Do not fax; original form is required.

Who may complete this form

A person who has a professional relationship with the applicant, including, but not limited to:

 Doctor

 Lawyer

 Shelter worker

 Law enforcement of icer

 Guidance counselor

 Registered social worker or so‐

cial service agency worker

 Member of the clergy

 Victim services worker

 Settlement services worker

 Community health care worker

 Counselor/psychologist

 An individual in a managerial or

client services position with London and Middlesex Housing Corporation

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Organization name Phone

Address

Professionalsprovidingveri icationmustcheckoffallofthefollowingstatements:

1. The applicant’s personal safety is signi icantly at risk. 2. All legal interventions have been exhausted.

3. I have reviewed the information about the veri ication process necessary to qualify for Urgent Social Status. The applicant to whom I have provided services/assistance and whose situation I am aware of should be considered for an Urgent Social Status transfer.

4. I am aware of my responsibility in providing veri ication and declare that the information I have provided is an ac‐ curate account of the applicant’s situation, to the best of my knowledge.

5. I have attached a letter providing an account of the appli‐ cant’s situation of abuse and remedies that have been at‐ tempted to resolve the situation.

6. I have a professional relationship with this client and am eligible to complete this form.

Yes No Yes No Yes No Yes No Yes No Yes No _________________________________________________ __________________________________

Signature of professional Date signed Please list the supporting documentation you are attaching to this form:

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Attachments

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Overhoused/underhoused

Bedroom size eligible for