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APPLICATION FORM FOR THE FINANCIAL ASSISTANCE PROGRAM FOR RESIDENTS OF HOUSEHOLDS MOST DIRECTLY AFFECTED BY THE PRESENCE OF PROTESTERS ON

THE DOUGLAS CREEK LANDS IN CALEDONIA

IMPORTANT INFORMATION

The Government of Ontario will provide financial assistance to eligible residents of Caledonia who have been most directly impacted by the former road blockades and the presence of protesters on the Douglas Creek lands. The eligible areas are as follows:

Residents in area 1A (see map):

Households on both sides of 6^th Line between Argyle St. S. and Oneida Road; the east side of Oneida Road between 6^th Line and Sterling Street; Sterling Street between the rail line and Oneida Road; and both sides of Argyle Street South, south of the location of the former road block and Highway 6.

Residents in area 1B (see map):

Households abutting the Southern Ontario Railway corridor on MacCrae Drive and Braemar Avenue; the households on Thistlemoor Drive abutting the Douglas Creek lands and the two residences on Thistlemoor backing on to the Notre Dame school; and the households on the west side of Argyle Street South between Celtic Drive and the area north of the former road block.

Residents in area 1C (see  map):

Households identified as "across the street" from those included in area 1B on Thistlemoor Dirve and Braemar Avenue. (Addresses include odd numbers from 1 to 41 Thistlemoor Drive, odd numbers 121 to 141 Braemar Avenue, 238 and 239 Kinross Street, and 23 Burnside Street.)

1        DETAILS OF ASSISTANCE:

This form allows eligible applicants to apply for a one-time payment per household in area 1A, or 1B, or 1C, based on residency in a household on the date of announcement of financial assistance, June 16, 2006. The level of assistance for the areas is as follows:

Area 1A - $6,000                Area 1B - $3,000                  Area 1C - $2,000

2        INSTRUCTIONS:

1.      Please ensure that you have read and understood the information before you complete this form.

2.      Please complete all sections on this form. PRINT clearly.

3.      Mail the completed from along with the required documentation, in the envelope provided, to the:

Ministry of Municipal Affairs and Housing

Municipal Services Office – Southwestern

659 Exeter Road, 2^nd Floor

London ON  N6E 1L3

4.      If you require assistance, please contact Jill Bellchamber-Glazier at 1-800-265-4736.

3        IDENTITY & ADDRESS VERIFICATION:

Please note, only one applicant may submit for each eligible household.

Personal Information
Mr. Mrs. Miss Ms.	Applicant's Last Name		First Name
Telephone (home)			Telephone (work)
Mailing Address                                                                                                       Postal Code
Street address or Lot and Concession
Co-Applicants		Last Name	Given Name(s)
Spouse or Partner
Children and Other Dependants

   □ Owner               □ Tenant

Please indicate which residential area, as described, qualifies you for eligibility:

□ Area 1A – Households on both sides of 6^th Line between Argyle St. S. and Oneida Road, the east side of Oneida Road between 6^th Line and Sterling Street; Sterling Street between the rail line and Oneida Road; and both sides of Argyle Street South, south of the location of the former road block and Highway 6.

OR

□ Area 1B – Households abutting the Southern Ontario Railway corridor on MacCrae Drive and Braemar Avenue; the households on Thistlemoor Drive abutting the Douglas Creek lands and the two residences on Thistlemoor backing on to the Nortre Dame school; and the households on the west side of Argyle St. S. between Celtic Drive and the area north of the former orad block.

OR

□ Area 1C – Households identified as "across the street" from those included in area 1B on Thistlemoor Drive and Braemar Avenue. (Addresses include odd numbers from 1 to 41 Thistlemoor Drive, odd numbers 121 to 141 Braemar Avenue, 238 and 239 Kinross Street, and 23 Burnside Street.)

Please submit documentation that verifies your identity, and address on June 16, 2006.

These documents must be present with your application. Check the box of the item you are using to confirm your identity, and address on June 16, 2006. If you cannot provide the documents required, please contact Jill Bellchamber-Glazier at  1-800-265-4736.

Please provide photocopies of the following:

□ One Piece of valid documentation to confirm identification and address )the address on the documentation must match the address/household you are claiming assistance for):

          □ Provincial Driver's License

        □ Passport

        □ Birth Certificate

        □ Other Government documentation (please identify) _____________________________

AND

□ One piece of valid documentation to confirm residency within an eligible area on June 16, 2006 (the name and address on the documentation must match the address/household you are claiming assistance for and must verify residency on June 16, 2006):

          □ Property Tax Statement

        □ Utility Bill (Telephone, Hydro, Water)

        □ Rent receipt

        □ Other (please identify) ­­­­­­­­­­­­­_______________________________

4        NOTICE OF COLLECTION OF PERSONAL INFORMATION:

Personal information contained in or required by an application for financial assistance program is being collected by the Ministry of Municipal Affairs and Housing for the proper administration of the financial assistance program in Caledonia. The personal information will be collected and used by the Ministry and Haldimand County to administer the program including processing applications, assessing eligibility for assistance, verifying information provided under the program, processing payments and performing audits. In addition, the information may be used in any action to recover payments made under the program where the Ministry determines that such payments are unauthorized. Inquiries about the collection of this personal information should be directed to:

Diane Mcarthur-Rodgers, Manager

Municipal Programs and Education Branch

Ministry of Municipal Affairs and Housing

3^rd Floor, 777 Bay Street, Toronto  ON  M5G 2E5

Tel: 416-585-7296

Any information created or obtained by any person, organization, or government body involved in the administration of this program is confidential and, except as required by law, shall be used and disclosed for the purpose of administration of assistance. The Freedom of Information and Protection of Privacy Act applies to any such information you provide.

All information will be kept strictly confidential, except for the purposes of verification and audit of the information you have submitted.

5        DECLARATION:

I declare/understand the address identified was directly impacted by the former Argyle Street road blockades and the continuing presence of protesters on the Douglas Creek lands in Caledonia; and that:

a)     all of the information provided in the application is true and that it will be subject to verification/audit:

b)     records will be maintained for a period of 2 years from the date of this application;

c)      I may be contacted for further information to assess and process this application;

d)     if any part of this claim is found to be false, Ontario may demand immediate repayment from the applicant and may avail itself of any legal remedies which it deems appropriate to recover repayment of the funds from the applicant;

e)     receipt of assistance under this program does not constitute an admission of liability on the part of the Government of Ontario;

f)        my application for the financial assistance program, does not affect my ability to participate in the proposed class action proceeding contemplated, in which the Province of Ontario, among others is named as a defendant. Any assistance I receive will be deducted from any damage award made by the Courts, if the proposed class action is certified and succeeds;

g)     I have been authorized to make this application on behalf of the co-applicants shown on part 3 of the application form.

I certify that all of the information provided above is true.

Dated at ________________________________, Ontario, this __________ day of _____________, 2007-03-19

________________________________________

Signature of Applicant

NOTE: DEADLINE FOR CLAIMS SUBMISSION IS APRIL 10, 2007