Financial Statement Disclosure

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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

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:   _____________________