City of London - Play Your Way Fund Application

Note: Fields marked with ★ are mandatory.

Section 1 - Applicant (main contact)

Please be aware if you do not complete the form properly and provide all required documentation, staff will notify you that you are to complete the form again. Please also note the maximum size limit for uploading a document is 4 MB.

First name:

Last name:

Date of birth:

Street address:

Apartment or unit number (if applicable):

Postal code:

Phone number:

E-mail address:

Section 2 - Proof of residency

Below is a list of applicable proofs of residency in London, Ontario. Please attach a current copy of one of the following:

rent receipts that show address and name of applicant
lease or mortgage agreement
property tax bill
current utility bill
current Child Tax Benefit statement
valid Ontario driver's license

Files accepted include .jpg, .jpeg, .png, or .pdf

Proof of residency.

Section 3 - Proof of identification

Please provide the name and date of birth of your spouse and children (if applicable).

Spouse

First name:

Last name:

Date of birth:

If this section above about a spouse is filled in, then you must also fill out the Proof of current annual family income section for the spouse as well.

First Child

First name:

Last name:

Date of birth:

Second Child

First name:

Last name:

Date of birth:

Third Child

First name:

Last name:

Date of birth:

Fourth Child

First name:

Last name:

Date of birth:

Fifth Child

First name:

Last name:

Date of birth:

Sixth Child

First name:

Last name:

Date of birth:

Seventh Child

First name:

Last name:

Date of birth:

Section 3 - Proof of identification (continued)

Please attach one document for each family member with proof of their identification (if applicable). Accepted documents include:

Birth Certificate
Canadian Citizenship, Permanent Resident Card, or Refugee document
Certificate of Indian Status
Valid Passport
Valid Driver's Licence
Ontario Photo ID card

Files accepted include .jpg, .jpeg, .png, or .pdf.

Applicant’s ID

Spouse’s ID

First Child’s ID

Second Child’s ID

Third Child’s ID

Fourth Child’s ID

Fifth Child’s ID

Sixth Child’s ID

Seventh Child’s ID

Section 4 - Proof of current annual family income

You are required to submit proof of income for all adults within the household.

Please provide your source or sources of income.

Please provide the name of the family member recieving the source or sources of income.

Please provide the annual income for your source or sources of income.

Please attach one document that contains your proof of income. Accepted documents include:

Notice of Assessment from Canada Revenue Agency (NOA) for the current year for each adult in the household, showing line #236 (net income)
Goods and Services Tax / Harmonized Sales Tax (GST / HST) from Canada Revenue Agency stating family net income
Canada Child Tax Benefit summary, showing family Adjusted Annual Income.

If you do not have these documents, we also accept the following documents:

Government benefits stubs such as OW, ODSP/ACSB, EIB, CCP, RAP, OAS, GAINS (current month)
Signed letter from a representative of a social service agency, religious institution, cultural organization or official refugee sponsor that lists all family members, verifies total family income and address.
other household income documents (child or spousal support, rental income, etc.)

Exceptions are made for asylum seekers and refugees new to Canada who are not able to provide the proof of income described above. As a proxy, these applications can provide landing documents such as Acknowledgement of Claim, Refugee Protection Claimant or enrolment in Interim Federal Health Program along with affirmation of family income. Applicants can re-apply for Play Your Way funding once sufficient time to file income taxes or apply for Child Care Tax Benefit has passed. In exceptional circumstances, if you are unable to provide proof of income documentation, you can request to complete an attestation as to your current situation including family income.

Files accepted include .jpg, .jpeg, .png, or .pdf.

Proof of income

Section 4 - Proof of current annual family income (Spouse)

If your spouse also has a source of income, please answer the questions listed below.

Please provide your spouse's source of income (if applicable).

Please provide your spouse's name (if applicable).

Please provide your spouse's annual income below (if applicable).

Please attach one document that contains your spouse's proof of income. Accepted documents include:

Canada Revenue Agency Notice of Assessment from the current year for each adult in the household, showing line #236 (net income)
Canada Revenue Agency Goods and Services Tax/Harmonized Sales Tax stating family net income
Canada Child Tax Benefit summary, showing family Adjusted Annual Income.

If you do not have these documents, we also accept the following documents:

Government benefits stubs, such as OW, ODSP/ACSB, EIB, CCP, OAS, GAINS (current month)
Two consecutive and current pay stubs
Other household income documents (child or spousal support, rental income, etc.).
Refugees may provide a copy of any government document that ocnfirms they are receiving support under the Resettlement Assistance Program or Interim Federal Health Program.

Files accepted include .jpg, .jpeg, .png, or .pdf.

Proof of spousal income

Section 4 - Proof of current annual family income (Dependent)

If your dependent also has a source of income, please answer the questions listed below.

Please provide your dependent's source of income (if applicable).

Please provide your dependent's name (if applicable).

Please provide your dependent's annual income below (if applicable).

Please attach one document that contains your child's proof of income. Accepted documents include:

Canada Revenue Agency Notice of Assessment from the current year for each adult in the household, showing line #236 (net income)
Canada Revenue Agency Goods and Services Tax/Harmonized Sales Tax stating family net income
Canada Child Tax Benefit summary, showing family Adjusted Annual Income.

If you do not have these documents, we also accept the following documents:

government benefits stubs, including OW, ODSP/ACSB, EIB, CCP, OAS, GAINS (current month)
Two consecutive and current pay stubs
Other household income documents (child or spousal support, rental income, etc.).
refugees may provide a copy of any government document that ocnfirms they are receiving support under the Resettlement Assistance Program or Interim Federal Health Program.

Files accepted include .jpg, .jpeg, .png, or .pdf.

Proof of child income

Authorization

The above information I have provided is true and complete to the best of my knowledge. All family members noted above are residents of London. I agree to accept financial responsibility for the services that myself or my family have registered in, should we be granted fee assistance based on false information. By checking this box and selecting submit below, I am providing authorization of my signature. Please note permission must be given by all adult members of the household listed above who are 18 and over.

Applicant Name

Co-Applicant Name (if applicable)

Today's Date

Thank you for your inquiry. Upon receipt of your submitted application, a member of the Recreation and Sport Customer Service Team will be in contact as soon as possible. Any general inquiries about this application can be emailed to recreation@london.ca.

The personal information collected on this application form is collected under the authority of the Municipal Act, 2001, as amended, and will be used to respond to Play Your Way Fund applicaitons submitted to the City of London from members of the public. Questions about this collection of personal information should be addressed to Supervisor, Customer Service, Recreation and Sport, City of London, 355 Wellington St, Suite 248, PO Box 5045, London, ON N6A 4L6. Tel: 519-661-CITY (2489) ext. 5579.

Note: If the form does not appear to submit, please open each section and confirm that there are no issues or missing required fields.