Income and Asset Information Section (IAIS): This section must be completed by each member of your household with income and assets. HOUSEHOLD MEMBER #1 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1. Please print your name Last Name: First name: Social Insurance Number Home Phone Number: Business Phone number: Fax number: (_______)___________________ (______)_________________ (________) ____________ 2. Your personal current income of all sources: Section Source of Income Type of income Date Date Gross monthly From To income, $ Section A Employment Company Name/Employer Employment Verification Company name/Employer Form signed by your Employer Section B Social Ontario Disability Support Payments Assistance Ontario Works Copies for Other verification Other Section C Type of Business: __________________________ Copies for Verification Section D Pension and Old Age Security Allowances Guaranteed Annual Income Supplement Copies for Verification Canada Pension Plan/ Quebec Pension Other Pension 3. Your personal assets Have you signed a Agreement to Sell Your “Standard Property? Yes No Section Assets Type of Assets Value, $ Section Income Producing All savings accounts, balance in $ E Assets Verification form Other accounts, balance in $ Section Non-Income Life Insurance, value in $ F Producing Assets Real Estate, value in $ (Please indicate all your assets) Other, value in $
Income and Asset Information Section (IAIS): This section must be completed by each member of your household with income and assets. HOUSEHOLD MEMBER #1 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 1. Please print your name Last Name: First name: Social Insurance Number Home Phone Number: (_______)___________________ Business Phone number: Fax number: (______)_________________ (________) ____________ 2. Your personal current income of all sources: Section Source of Income Type of income Date From Date To Gross monthly income, $ Section A Employment Employment Verification Form signed by your Employer Company Name/Employer Company name/Employer Section B Social Assistance Copies for verification Ontario Disability Support Payments Ontario Works Other Other Section C Copies for Verification Type of Business: __________________________ Section D Pension and Allowances Copies for Verification Old Age Security Guaranteed Annual Income Supplement Canada Pension Plan/ Quebec Pension Other Pension 3. Your personal assets Have you signed a “Standard Agreement to Sell Your Property? Yes No Section Assets Type of Assets Value, $ Section E Income Producing Assets Verification form All savings accounts, balance in $ Other accounts, balance in $ Section F Non-Income Producing Assets (Please indicate all your assets) Life Insurance, value in $ Real Estate, value in $ Other, value in $
add_household_member_-_2015.docx