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Ma Nîķi (My Home) Métis Seniors Housing Renovation Pilot Program

SINGLE APPLICANT:

NAME: (FIRST, LAST NAME)

ADDRESS: STREET ADDRESS

CITY, PROVINCE, POSTAL CODE

EMAIL:

PHONE NUMBER:

DATE OF BIRTH:

SOCIAL INSURANCE NUMBER:

MNBC CITIZENSHIP NUMBER:

TOTAL ANNUAL HOUSEHOLD INCOME: BRIEF DESCRIPTION OF RENOVATIONS:

PLEASE ENSURE YOU HAVE INCLUDED THE FOLLOWING IN YOUR APPLICATION:

PROOF OF HOME OWNERSHIP (Tax receipt, assessment notice, or title search) INCOME TAX NOTICE OF ASSESSMENT FOR THE LATEST FISCAL YEAR (2019) COMPLETED AND SIGNED APPLICATION FORM

APPLICANTS ARE REQUIRED TO PROVIDE A WRITTEN QUOTATION OF SCOPE OF WORK FROM A QUALIFIED CONTRACTOR WITHIN 30 DAYS OF THEIR INITIAL APPLICATION SUBMISSION. IF A WRITTEN QUOTATION IS NOT RECEIVED BY MNBC WITHIN 30 DAYS, THE APPLICATION WILL LOSE ORDER OF PREFERENCE.

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED BY MNBC.

BC

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Declaration of Truth and Consent:

• The applicant declares that all the information given in this application form is true andcomplete and that the gross annual income declared is factual and true.

• The applicant declares that they are a current MNBC Citizen. One person on the title to thehome must be a MNBC Citizen.

• The applicant is responsible for fulfilling the terms of the Ma Nîķi Métis Seniors HousingRenovation Pilot Program, regardless of their names being removed from title to the property.

• The Métis citizen applicant declares that he or she has not applied for First Nation status underBill C-31, Bill C-3 or Bill S-3 or any other government legislation. The MNBC Central RegistryOffice will periodically verify that grant recipients maintain MNBC Citizenship.

• The applicant declares that the property listed in this application form is the home andproperty of the applicant and is the principle family residence of the title holder.

• The applicant declares that the property listed in this application form does not have anoutstanding lien or reverse mortgage.

• The applicant acknowledges and agrees that any work started before getting approval inwriting from the MNBC Housing Department is not eligible for program funding.

• The applicant gives consent to MNBC and its agents to investigate and disclose any of thefacts given in this application form for internal purposes or to other agencies for any of thesereasons:

- to confirm household income; - to confirm eligibility for program funding; - to collect any amount owing to MNBC; - to program funding partners for audit purposes.

• The applicant agrees to reimburse MNBC the full amount of funding if they have not madefull and accurate disclosure of information and/or work undertaken by them is found tonot be in compliance with the contract.

• The applicant authorizes MNBC or its agents to conduct an inspection(s) of the applicant’s homeand property, and request and audit financial documentation for the purposes of confirming thecompletion of the work and compliance of the Ma Nîķi Métis Seniors Housing Renovation PilotProgram.

• The applicant agrees to reimburse MNBC for any work deemed to be ineligible and/or not incompliance with the contract.

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• The applicant agrees to reimburse MNBC for the full amount of the grant if the residence is soldwithin five years of the approved grant date.

• The applicant acknowledges and agrees that the facts given in this application form will be keptand disposed of as required by the Information Management Act.

• The applicant agrees that MNBC may collect data and contact them from time totime for the purpose of conducting any client-related surveys about Home RepairPrograms.

• The applicant understands that this application does not obligate MNBC to approve funding.• All applicants who give personal information to MNBC shall be required to consent to the release

of that information to MNBC in order to comply with the BC Personal Information Protection Act(PIPA) and Freedom of Information and Protection of Privacy Act (FIPPA).

Applicant Signature Date