To be considered for financial assistance in order to attend a Case Development (CD) and/or a mediation meeting, an applicant must complete and sign this financial statement.
Once completed, please return to the York Region Housing Mediation Services® for approval and processing.
You can return the form by email at info@yrhms.ca
By postal mail to:
York Region Housing Mediation Services®
c/o Housing Help Centre, 10271 Yonge Street, Unit #303, Richmond Hill, ON L4C 3B5
By Fax to: 905-508-1237
Attention: York Region Housing Mediation Services® (YRHMS)
Name: ____________________________________________________
Current Address: ____________________________________________________
| Household After Tax Income |
|
| Household Combined Savings |
|
| Number of People Living in Home
|
|
| Household Monthly Expenses: | |
| – Rent | |
| – Heat | |
| – Water | |
| – Food | |
| – Travel | |
| – Other |
Signature: ________________________________ Date: ________________
—————————————————————————————–For Office Use Only
Case Number: __________ Transportation Assistance Granted: YES q No q
Approve by: ______________________________
Date: _____________________