Trusteeship Application FormPlease enable JavaScript in your browser to complete this form.Person being referred *FirstLastCurrent city or preferred city *Age range of person being referred *16 – 1718-2425-3435-4445-5455-6465-7575+I am referring *My SelfMy ClientA family memberA friend or aquaintanceDoes the person being referred have a bank account? *YesNoUnsureWhat are the reasons for this referral? (Select all that apply) *History of late payment of rentHousehold struggles with money management that impacts housingThreat of imminent eviction, including LTB orders, sheriff eviction etc., has been confirmedPay direct from social assistance is not possibleFamily or friend can’t manage Trusteeship anymore and wants someone else to take overLandlord or other person has said it is a requirementODSP or OW Case Manager is mandating TrusteeshipHistory of chronic homelessnessOther support agency or social worder would like individual to be on TrusteeshipMoved into area – referral from other agency-based trusteeship programNot capable of managing their money or affairsOtherIf other please specifyClient source(s) of income (Check all that apply) *ODSPOWFACS - VYSAFACS - Ready-Set_GoWSIBCPPCPP-DisabilityOASWork PensionEmployment: Self-EmploymentLong Term Disability from workOtherIf Other, please specifyCurrent housing situation *Private market apartment with leaseRenting a room in a hosue or sharing apartmentAffordable, social or co-op housingHoused with familySupportive livingTransitional programCouchsurfingShelterLiving on street, vehicle or encampentotherIf other, please specifyIs the rent being paid directly through social assistance or through automatic payments from a bank account? *YesNoUnsurePlease describe what attempts have already been made to address the issues or concerns *Please provide any additional information about this referral that would be helpful for us to knowPlease list all other agencies and/or support workers involved with client know being person Name of contact person to discuss referral: *FirstLastPhone number of contact person *Email of contact person *Submit Please enable JavaScript in your browser to complete this form.Person being referred *FirstLastCurrent city or preferred city *Age range of person being referred *16 – 1718-2425-3435-4445-5455-6465-7575+I am referring *My SelfMy ClientA family memberA friend or aquaintanceDoes the person being referred have a bank account? *YesNoUnsureWhat are the reasons for this referral? (Select all that apply) *History of late payment of rentHousehold struggles with money management that impacts housingThreat of imminent eviction, including LTB orders, sheriff eviction etc., has been confirmedPay direct from social assistance is not possibleFamily or friend can’t manage Trusteeship anymore and wants someone else to take overLandlord or other person has said it is a requirementODSP or OW Case Manager is mandating TrusteeshipHistory of chronic homelessnessOther support agency or social worder would like individual to be on TrusteeshipMoved into area – referral from other agency-based trusteeship programNot capable of managing their money or affairsOther us are If other please specifyClient source(s) of income (Check all that apply) *ODSPOWFACS – VYSAFACS – Ready-Set_GoWSIBCPPCPP-DisabilityOASWork PensionEmployment: Self-EmploymentLong Term Disability from workOtherIf Other, please specifyCurrent housing situation *Private market apartment with leaseRenting a room in a hosue or sharing apartmentAffordable, social or co-op housingHoused with familySupportive livingTransitional programCouchsurfingShelterLiving on street, vehicle or encampentotherIf other, please specifyIs the rent being paid directly through social assistance or through automatic payments from a bank account? *YesNoUnsurePlease describe what attempts have already been made to address the issues or concerns *Please provide any additional information about this referral that would be helpful for us to knowPlease list all other agencies and/or support workers involved with clientName of contact person to discuss referral: *FirstLastPhone number of contact person *Email of contact person *Submit
