H2O Fund
(Help 2 Others Fund)
April 2014 – March 2015
H2O Fund Administrator
2038/2044 Gottingen Street
Halifax NS B3K 3A9
Tel: 902-422-3435 Fax: 902-444-8914
[email protected]
Applications Available: www.halifaxwater.ca
www.salvationarmy.ca/maritime/H2O
The H2O (Help 2 Others) Fund assists low income households with the cost of
residential water and waste water in an emergency situation if eligibility guidelines are met.
To be considered for assistance, the applicant must meet the following criteria:
1. The household is low income and in an emergency situation.
 Income documents are required for every person in the household. All income, taxable and non taxable, must be
reported including, but not limited to: Wages, Employment Insurance, Worker’s Compensation, Income Assistance,
Child Tax Benefit, Child Support, Old Age Security, Canada Pension, private pension, etc.
 A household is determined to be in an emergency situation when there are no resources to pay the Halifax Water bill
and/or the household is about to face disconnection.
2. The Halifax Water account is active and in the name of an adult living in the household.
 The account and usage is current. Closed accounts are not eligible for assistance.
 Accounts in the name of anyone who does not live in the household are not eligible for assistance.
3. The household and household members have not received H2O Fund assistance within the last 24 months.
4. The Halifax Water account holder completes & submits an application.
 Application must include all requested information, including supporting documents at the time of submission.
 Incomplete applications will not be considered and will be returned by mail.
THE FOLLOWING DOCUMENTS ARE REQUIRED & MUST BE SUBMITTED WITH EVERY APPLICATION:
1. CONFIRMATION OF HALIFAX WATER ACCOUNT
→ Provide a copy of the most recent water bill which shows applicant’s name, address, account number & amount owing.
2. CONFIRMATION OF INCOME or EDUCATIONAL ENROLLMENT
→ Provide a copy of most recent income document(s) for each adult (18 years & older) member of the household.
→ Include all household income, taxable and non taxable. This includes Child Support, Child Tax Benefits, Guaranteed Income Supplement,
Old Age Security, Canada Pension Plan, Employment Insurance, Worker’s Compensation, Wages, etc.
→ Acceptable income documents include cheque stub(s) or a bank statement if it provides a list of all deposits within the last 30 days.
→ If someone in the household attends school, include a document (copy of report card, student ID, letter) which confirms enrollment.
→ Income & school documents need to show name and address.
The H2O Fund is intended to assist households in an emergency. It is not a rebate program and submitting an application does not
guarantee assistance. To be considered for assistance, the application must be complete and supporting documents are required at
the time of application submission. Incomplete applications will not be considered.
Please allow 5 business days for your application to be reviewed; you will be contacted by phone after a decision is made. If your
application is approved, a payment will be made directly to your Halifax Water account.
If you have any questions, please contact the H2O Fund Administrator (contact information is noted in the top right corner of this page).
Return the completed application, along with the required supporting documents, to the attention of the H2O Fund Administrator by
mail, fax or email.
*****PLEASE KEEP A COPY OF THIS LETTER FOR YOUR REFERENCE*****
Contact information for the H2O Fund Administrator is noted on the top right corner.
The H2O Fund is administered by the Salvation Army and dependent on contributions from Halifax Water & their employees.
H2O Fund
(Help 2 Others Fund)
April 2014 – March 2015
H2O Fund Administrator
2038/2044 Gottingen Street
Halifax NS B3K 3A9
Tel: 902-422-3435 Fax: 902-444-8914
[email protected]
Applications Available: www.halifaxwater.ca
www.salvationarmy.ca/maritime/H2O
If you are interested in receiving information on reducing water consumption, call 490-4820 or visit www.halifaxwater.ca.
APPLICANT INFORMATION- Please Print
NAME: __________________________________________________________________
HOME PHONE: ______________________________
ADDRESS: _______________________________________________________________ CELL PHONE: _______________________________
CITY/TOWN & POSTAL CODE: ______________________________________________
EMAIL: _____________________________________
Are you responsible to pay for your home water bill? YES / NO Amount owing? ___________ Halifax Water Account # _______________
HOUSEHOLD & INCOME INFORMATION- Please Print
TOTAL NUMBER OF INDIVIDUALS CURRENTLY LIVING IN HOUSEHOLD: ___________
Do you OWN or RENT? OWN / RENT
FIRST & LAST NAMES OF
ALL HOUSEHOLD MEMBERS
BIRTH DATES
(Month/Day/Year)
HEALTH CARD NUMBERS
NAME OF PERSON RECEIVING INCOME
TYPE OF INCOME
(Wages, Child Tax Benefit, OAS, etc.)
MONTHLY NET INCOME
APPLICANT STATEMENT
I certify the information provided on this application is an accurate and complete disclosure of the requested information. I authorize
H2O Fund Administrators to contact Halifax Water and/or my landlord and/or my social worker for verification or additional information. I
understand that filling out this application does not guarantee my household will receive assistance.
APPLICANT NAME:
WITNESS NAME:
APPLICANT SIGNATURE:
RELATIONSHIP TO APPLICANT:
DATE:
WITNESS PHONE # :
OFFICE USE ONLY
DECISION & DATE:
AMOUNT: $
STAFF NAME:
CMS HOUSEHOLD ID #: