LEAP - Application Form

If you have questions or concerns before filling out this application, please contact Port Cares at the following phone numbers:

Port Colborne / Wainfleet - 905-834-3629

Fort Erie - 905-994-5276

APPLICANT INFORMATION

HOUSEHOLD MONTHLY INCOME (AFTER TAX)

*Include income for all household members 18+ years

Income Breakdown (leave blank if N/A)

DECLARATION

Declare that the information provided in this application for a LEAP grant is true, to the best of my knowledge, and i am not withholding information that would have an impact on this eligibility grant.

• Consent to Port Cares to verify and/or exchange information with the utility company solely for the purpose in determining eligibility for a LEAP grant
• Fully understand and agree in the event I deliverately provide false information (for the purpose of qualifying for a LEAP grant), will constitute denial of a LEAP grant
• To the best of my knowledge, I have not received a LEAP grant within the last twelve (12) months.
• The completion of an application for a LEAP grant does not signify elgibility for a grant
• Port Cares will not be held responsible and/or assume any liability relating to delay, cancellation and/or denial of a LEAP grant resulting in the disconnecton of the participant's utility
• Refusal of signing and/or an incomplete LEAP application, will result in not proceeding in determining grant eligibility.

I have read, understand and fully agree to the above noted Declaraction conditions.

CONSENT TO COLLECT, RELEASE, USE, STORE AND DISCLOSE INFORMATION

In accordance with The Federal Personal Information Protection and Electronic Documents Act (PIPEDA); The Personal Health Information Protection Act (PHIPA) of Ontario; Ontario's Freedom of Information and Protection of Privacy Act (FIPPA) and the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA)

Hereby consent to the collection, use, storage and disclosure of my personal information with:

CANADIAN NIAGARA POWER

Thank you for filling out the LEAP application form. Should you be eligible, there will be a couple documents required. To save us all some time, you are able to submit those documents directly to this questionnaire! The documents required are as follows:

• Photo ID's for each household member. Two Photo ID's required for the primary applicant
• Copy of current CNP bill
• Notice of Disconnection (if applicable)
• Proof of household income
• Bank Statements
• Copy of rent or mortgage receipt 

If you do not have those documents handy, or would simply like to provide those documents in person, please tick "Later" for the following question.

If you would like to submit this information online but do not have the information on hand, click "Save" below to create a draft, and then "Skip Create an Account" if you do not have a jotform account. You will get the option to send the draft link to your email, or save the draft link directly.