fee assistance program

Fee Assistance Program Application

FOR OFFICE USE ONLY Max. Qualifying Net Income

Please provide one or more of the following documents showing net income/earnings for all adults below the Family Size
1 person . . . . . . . . . . . . . .
. . . . . . . . . . . . $20,675
designated cut off as well as documents showing legal responsibility of children. All current original documents
2 persons . . . . . . . . . . . .
. . . . . . . . . . . $25,163
(no
andphotocopies) and presented in full.
presented in full.
3 persons . . . . . . . . . . .
. . . . . . . . . . . . $31,334
4 persons . . . . . . . . . . .
. . . . . . . . . . $39,092
Canada Customs and Revenue Agency (CRA)
(CRA) Notice of Assessment form (T451, line 236) 5 persons . . . . . . . . . .
. . . . . . . . . . $44,514
(YEAR/MONTH/DAY): 1) 2) 6 persons . . . . . . . . . . .
. . . . . . . . . . . $49,367
7 or more persons . . . . . $54,220
Ontario Disabilities
Ontario Disabilities Support
Support Program
Program Drug
Drug Benefit
Benefit Eligibility
Eligibility Card
Card ((YEAR/MONTH/DAY):
YEAR/MONTH/DAY):
Ontario Works Drug/Dental Benefit Eligibility Card (YEAR/MONTH/DAY):
Ontario Works Drug/Dental Benefit Eligibility Card (YEAR/MONTH/DAY): Staff verification: (PRINT name and
Canada Child Tax Benefit Notice (YEAR/MONTH/DAY): initial)

Canada
Ontario Child Tax Benefit
Child Care Noticefor
Supplement (YEAR/MONTH/DAY ): Entitlement Notice (YEAR/MONTH/DAY):
Working Families
Ontarioand
Goods Child Care Supplement
Services for Working
Tax/Harmonized Sales Families Entitlement
Tax Credit Notice (YEAR/MONTH/DAY
Notice (YEAR/MONTH/DAY ): ):
Staff verification: (PRINT name and
Ontario Sales
Goods and Tax Benefit
Services (YEAR/MONTH/DAY
Tax/Harmonized Sales):Tax Credit Notice (YEAR/MONTH/DAY): initial)

Confirmation of Permanent Residency for each family member (YEAR/MONTH/DAY):

Ontario Sales Tax Benefit (YEAR/MONTH/DAY):
PR Category
Name of receiving Community Centre
Confirmation of Permanent Residency for each family member (YEAR/MONTH/DAY):
Proof of Residency

MAIN CONTACT: (MUST PROVIDE CURRENT SUPPORTING DOCUMENTATION - see back)

LAST Name (required information) FIRST Name (required information) MALE SINGLE/
DIVORCED/
FEMALE
WIDOWED
E-MAIL Address (program confirmation will be sent via e-mail) OPT OUT
STUDENT
65+ YRS
HOME Phone (required information) CELL Phone BUSINESS Phone EXTENSION MARRIED/
COMMON LAW

ADDRESS: Street Number / Street Name Suite / Apartment / Unit

CITY / PROVINCE POSTAL Code

List all other family members, including spouse and/or eligible dependents who live in the household (Persons 16 years of age and older must initial
beside their name). Please indicate any family members who do not wish to receive subsidy by checking the OPT OUT box.

LAST Name FIRST Name BIRTH Date (Year/Month/Day) M or F INITIALS

OPT OUT

LAST Name FIRST Name BIRTH Date (Year/Month/Day) M or F INITIALS

OPT OUT

LAST Name FIRST Name BIRTH Date (Year/Month/Day) M or F INITIALS

OPT OUT

LAST Name FIRST Name BIRTH Date (Year/Month/Day) M or F INITIALS

OPT OUT

LAST Name FIRST Name BIRTH Date (Year/Month/Day) M or F INITIALS

OPT OUT

LAST Name FIRST Name BIRTH Date (Year/Month/Day) M or F INITIALS

OPT OUT

How long have you lived in Canada? Are you currently accessing other recreation or sport subsidies (ie Jump Start, Jerry Love Children’s Fund)?
Born in Canada, 0-2 years 3-5 years over 5 years (check box) yes no. If yes:

I, the undersigned, certify the information set forth in this application is true and complete to the best of my knowledge. I understand that it is my obligation
OFFICE USE ONLY
to update my Recreation account if any changes occur in my family’s financial situation. I understand that this updated information may terminate my eligibility
for the program. I understand that any falsified statements on this application or inability to provide documentation upon request can result in termination of New ActiveAssist
applicant
any financial assistance granted by the City of Mississauga, Recreation Division. To ensure that available subsidies help as many residents of Mississauga as
ExistingActive
possible, I am not currently receiving another City-administered subsidy. I also understand that the information provided may be utilised for evaluation/research Assist Recipient
purposes and I may be contacted by email/ post mail/ phone to provide feedback during participation in the fee assistance program. Participation in research Expires:
is not a requirement for continued Active Assist funding.
New Recreation
Account
Signature: _______________________________ Date: __________________________

06/16
Form rev. 05/17
 fee assistance program
Support Documentation

TO BE ELIGIBLE FOR ACTIVEASSIST THE FOLLOWING FORMS MUST BE SHOWN TO STAFF:

Where possible, forms must be original issue copies. We will accept online printouts in some cases.

√ Proof of Mississauga residency

√ Canadian documentation to show total individual or family net income; and
√ Proof of legal responsibility for all dependents

PROOF OF RESIDENCY: PROOF OF INCOME: PROOF OF LEGAL

A document that displays your A document that verifies your RESPONSIBILITY FOR
name, current home address, total individual or family net DEPENDENTS:
and confirms that your primary income. A document that verifies that
place of residence is in the City you have dependents that you
of Mississauga. are legally responsible for.

• Canada Child Benefit Notice NET FAMILY INCOME: • Canada Child Benefit Notice
• Good & Services Tax/ • Canada Child Benefit Notice • Good & Services Tax/
Harmonized Sales Tax • Good & Services Tax/ Harmonized Sales Tax
Credit Notice Harmonized Sales Tax Credit Notice
• Ontario Child Care Credit Notice • Ontario Child Care
Supplement for Working • Ontario Child Care Supplement for Working
Families Entitlement Notice Supplement for Working Families Entitlement Notice
• Valid Ontario Driver’s Licence Families Entitlement Notice • Ontario Works and Ontario
or Temporary Driver’s Licence • Ontario Works and Ontario Disability Program Drug
(only if accompanied by photo Disability Program Drug Benefit Eligibility Card
licence card with same address Benefit Eligibility Card
• Utility bill (home telephone,
cable TV, public utilities NET INDIVIDUAL INCOME: REFUGEES
commission, hydro, gas, water • Canada Customs & Revenue
Agency (CRA) Notice of Refugees are eligible to apply
• Valid Ontario Photo Card for ActiveAssist within the first
• Property tax bill Assessment (T451)
year of receiving the following
• Insurance policy (home, documents which proves refugee
tenant, auto or life) status and eligibility. Only these
• Mortgage, rental or lease DOCUMENTS CONTAINING ALL
documents are required to
agreement ELIGIBILITY REQUIREMENTS: validate family members and
• Canada Child Benefit Notice Mississauga residency; income
NOTE: The City of Mississauga • Goods and Services is not a requirement:
reserves the right to request Tax/Harmonized Sales • Confirmation of permanent
additional documentation. All Tax Credit Notice residency OR the Government
support documents must be • Ontario Child Care of Canada - Permanent
from the most current tax year. Supplement For Working Resident Card indicating
Personal information on this form is collected by the Families Notice refugee status, or the Refugee
City of Mississauga under the authority of Section 11 Protection Claimant Document
of the Municipal Act, 2001 and the City of Mississauga (each document above verifies all
policy 08-03-06 and will be used for the purpose of or a lease/rental agreement.
ActiveAssist Fee Assistance program administration; three eligibility criteria)
contacting you to provide feedback during participation • Bank Information
in the program; and periodic mailings pertaining to
ActiveAssist and registered programs. Your information (identifies permanent
may also be used for evaluation and research purposes
for the program.
Mississauga address)
Questions about this collection should be directed to:
Manager, Recreation, Customer Service Centre, 301
Burnhamthorpe Rd W, Ground Floor, Mississauga ON
L5B 3Y3 Tel: 905-615-4100.