Text Form 2024 - Flavio R I Barbieri

Holiday 2024 (Internal)

You will be required to provide the following:

Name

Proof of North Bay Address

Phone/Contact Number

Rent/Mortgage Proof of payment.

Utility Bills Hydro, gas, water etc.

60 Days Bank Statement

Must show your name, balance and ALL activity for the past 60 days.

Only a deposit of Canada Child Benefit (CCB) into your bank account will be accepted as proof that your child/children reside with you.

Hidden

LIPI ID – UNIQUE CODE

Hidden

SA ID – UNIQUE CODE

Hidden

Where are you applying from?(Required)

Online

LIPI Office

Staff Initials(Required)

What is your household type:(Required)

Basic Needs Primary – Single(Required)

Basic Needs Primary – Couple(Required)

Information of applicant

Name(Required)

First Last

Date of Birth (dd/mm/yyyy)(Required)

Partner / Spouse

Name(Required)

First Last

Date of Birth (dd/mm/yyyy)(Required)

Contact Information

Phone(Required)

Email(Required)

Consent

First Consent(Required)

I/We further consent to the release of information about my case by any representative of the Low Income People Involvement to such person as that representative considers necessary in order to represent me/us, subject to any express instuctions from me/us.

First Consent(Required)

I/We further consent to the release of information about my case by any representative of the Salvation Army/Low Income People Involvement to such person as that representative considers necessary in order to represent me/us, subject to any express instuctions from me/us.

Second Consent(Required)

I/We of the District of Nipissing, in the Province of Ontario, hereby give my permission and authorize you providing information to any representative of Low Income People Involvement.

Second Consent(Required)

I/We of the District of Nipissing, in the Province of Ontario, hereby give my permission and authorize you providing information to any representative of Salvation Army/Low Income People Involvement.

Address

Applicant Address(Required)

Apt no./House no. and Street name City Province Postal Code

Special Instructions for delivery:

Children

Number of Children:(Required)

Please enter a number from 0 to 12.

Child 1

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 2

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 3

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 4

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 5

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 6

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 7

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 8

Name 6(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 9

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 10

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 11

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Child 12

Name(Required)

First Last

Gender(Required)

Preferred gender(Required)

Date of Birth (dd/mm/yyyy)(Required)

Age(Required)

Please enter a number from 0 to 19.

Favourite Colour?

Favourite Character?

PJ Size?(Required)

Shoe Size?

Please enter a number from 0 to 17.

Check all that applies to your child:

Does your child collect anything? For example: hockey cards, stamps etc(Required)

Yes

What do they collect?(Required)

Brief description of wish list or special needs

Children – Basic Needs

Dependent Basic Needs

Income

Household Income – Tick all that apply(Required)

Employment

CCB – Canada Child Benefit

OW – Ontario Works

ODSP – Ontario Disability Support Program

EI – Employment Insurance

OTB – Ontario Trillium Benefit

Other 1

Other 2

Monthly Employment Income(Required)

Monthly CCB Amount(Required)

Monthly OW Amount(Required)

Monthly ODSP Amount(Required)

Monthly EI Amount(Required)

Monthly OTB Amount(Required)

Details/Description of Other Income 1(Required)

Other 1 Income Amount(Required)

Details/Description of Other Income 2(Required)

Other 2 Income Amount(Required)

Expenses

Do you pay for rent or mortgage?

How much do you pay for rent/mortgage monthly?(Required)

Do you pay for hydro?

How much do you pay for hydro monthly?(Required)

Do you pay for gas?

How much do you pay for gas monthly?(Required)

Do you pay for water?

How much do you pay for water monthly?(Required)

Do you pay for life insurance?

How much do you pay for life insurance monthly?(Required)

Do you pay for content/tenant insurance?

How much do you pay for content/tenant insurance monthly?(Required)

Totals

Total Income

Check if Total Income is correct(Required)

Please check the information above. If the information is Correct, please check this box

Total Expenses

Basic Needs

Disposable Income

Documentation Check-list

Documents provided

Bank Account

Proof of Income

Proof of Rent

Proof of Custory

Hydro Bill

Gas Bill

Water Bill

Submit Holiday Form by pressing the button below. Please be patient. Uploads can take a minute or two.

Holiday 2024 (Internal)

Information of applicant

Partner / Spouse

Contact Information

Consent

Address

Children

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8

Child 9

Child 10

Child 11

Child 12

Children – Basic Needs

Income

Expenses

Totals

Documentation Check-list

don't leave it to the last minute!

Check our
income tax Page

Holiday 2024 (Internal)

Information of applicant

Partner / Spouse

Contact Information

Consent

Address

Children

Child 1

Child 2

Child 3

Child 4

Child 5

Child 6

Child 7

Child 8

Child 9

Child 10

Child 11

Child 12

Children – Basic Needs

Income

Expenses

Totals

Documentation Check-list

don't leave it to the last minute!

Check our income tax Page

Check our
income tax Page