Urgent Status Request and Verification form - Social Services

REQUEST FOR URGENT STATUSALL PAGES/SECTIONS OF THE REQUEST FORM MUST BE COMPLETEDWhat is Urgent Status? In order for an applicant to be considered to have an Urgent need for permanentaffordable housing, the household’s income would require them to pay 50% or more of the gross householdincome for the market rent for the bedroom size required AND meet one or more of the following criteria:Homelessness Are living on the street(no shelter), OR using the emergency shelter system as their primary residency;or People who have no permanent home as a result of its being destroyed by fire or natural disaster withinthe last three (3) months; or Be awaiting release from hospital or other time limited treatment facility and can not return to formerplace of residence and will not be released until suitable housing is found; orSeparated Families Be a family whose children will not be returned by a child protection agency due to the household nothaving adequate housing AND lack of adequate housing is the only protection issue outstanding; orSafetyWhere the physical condition of the applicant household’s current housing poses a serious andimmediate threat to the applicant household’s safety and cannot be repaired or remedied within areasonable time; OR the applicant household must relocate as a result of being subjected to actual orthreatened physical harm.APPLICANTS ASSIGNED URGENT STATUS ARE OFFERED 1 IN 10 VACANCIES AND ARE ONLY ENTITLEDTO REFUSE ONE OFFER OF HOUSING BEFORE LOSING THIS STATUSWho may request Urgent Status: Any member of a household applying for rent-geared-to-income (RGI)assistance, that is 16 years or older, may request the household be given Urgent status. Where the householdmember experiencing the urgent situation is under the age of 16, the request can be made on their behalf byanother member of the household.Requesting Urgent StatusIn order to request Urgent status, please complete all sections of this form and attach a VerificationDeclaration completed by an individual who can verify the urgent situation.Name of Applicant: _______________________________Birth date:________________Consent to the Sharing of Information and/or DocumentationI, ________________________, consent to the sharing of all information and/or documentation relating to my request forUrgent Status with housing providers, the Region of Waterloo’s housing staff and Access site staff that are part of theRegion of Waterloo Co-ordinated Access System, for the purpose of verifying the information and/or documentationprovided to determine my eligibility for Urgent Status.Signature of Applicant ______________________________________ Date _______________Witness __________________________________________________ Date _______________ROWCAS FORM F009348286 Revised: October 2008COMMUNITY HOUSING ACCESS CENTRE235 King Street East, 6 th Floor, Kitchener, ON N2G 4N5Phone: (519) 575-4833 Fax: (519) 893-8648Email: chac@region.waterloo.on.ca

COMMUNITY HOUSING ACCESS CENTRE235 King Street East, 6 th Floor, Kitchener, ON N2G 4N5Phone: (519) 575-4833 Fax: (519) 893-8648Email: chac@region.waterloo.on.caVERIFICATION DECLARATION FOR URGENT STATUSImportant Note to Person Completing this Form:As receiving Urgent status may allow applicants to move ahead of other applicants on waitinglists for housing, the Region of Waterloo Co-ordinated Access System (ROWCAS) must ensurethat this status is reserved for those who truly need it. In order to assess an applicant’s requestfor Urgent status, written verification of the applicant’s situation is required from someone whois not a member of the household, and is acting on behalf of the applicant in a professionalcapacity.Note: Deliberately providing false or inaccurate information for the purpose of receivingpriority for RGI assistance will affect your status and eligibility for housing.Verification ProcessThe applicant from whom you have received this form has applied for subsidized housing andmay be eligible for Urgent status due to their present circumstances. In order to qualify for theUrgent status, the applicant’s situation must correspond to at least one of the followingindicators:Homelessness Are living on the street (no shelter), OR using the emergency shelter system as their primaryresidence; or People who have no permanent home as a result of its being destroyed by fire or natural disasterwithin the last three (3) months; or Be awaiting release from hospital or other time limited treatment facility and can not return toformer place of residence and will not be released until suitable housing is found; orSeparated Families Be a family whose children will not be returned by a child protection agency due to the householdnot having adequate housing AND lack of adequate housing is the only protection issueoutstanding; orSafetyWhere the physical condition of the applicant household’s current housing poses a serious andimmediate threat to the applicant household’s safety and cannot be repaired or remedied within areasonable time; OR the applicant household must relocate as a result of being subjected to actualor threatened physical harm.Who May Complete this Form?This form may be completed by: a shelter worker, social worker, social services worker,community health care worker, doctor, law enforcement officer, teacher/guidance counselor,member of the clergy, or other service agency or medical care facility staff with knowledge ofthe applicant’s urgent situation.Please ensure all sections of the form have been completed, and that it has been signed, witnessed and dated.Page 1 of 2

COMMUNITY HOUSING ACCESS CENTRE235 King Street East, 6 th Floor, Kitchener, ON N2G 4N5Phone: (519) 575-4833 Fax: (519) 893-8648Email: chac@region.waterloo.on.caVERIFICATION DECLARATION FOR URGENT STATUSVerification Completed By:NAME POSITION ORGANIZATIONADDRESS POSTAL CODE TELEPHONEName of Applicant: _______________________________ Birth date: ____________________□□I have reviewed the information about the Verification Process necessary to access subsidizedhousing under the Urgent status. The applicant (named above), to whom I have provided services/assistance and whose urgent situation I am aware of, should be given Urgent status.I am aware of my responsibilities in providing verification information and declare that theinformation I am providing is a true and accurate account of the applicant's situation.□ The following statement summarizes my knowledge of the urgent situation experienced by theapplicant named above:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________OR□The attached letter/document summarizes my knowledge of the urgent situation experienced bythe applicant named above.SIGNATUREDATENAME OF SUPERVISOR/DIRECTOR SIGNATURE DATEIf you have questions regarding Urgent status and/or the completion of these forms, please contact the CommunityHousing Access Centre at (519) 575-4833.ROWCAS FORM F010 Page 2 of 2143837 Revised: October 2008