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Consent For Release of Information Form

If you require any assistance completing this form please don't hesitate to contact us at (705)748-8830.

to employees of the City of Peterborough and/or other third parties (landlord, utility provider) as required for the purposes of determining and verifying eligibility for, and issuing benefits as outlined in the City of Peterborough Housing Stability Fund Policy.

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Once signed, this consent form will be valid for the period of one year. You may withdraw your consent at any time by giving notice in writing to the Social Services Division, PO Box 4138, 178 Charlotte Street, Peterborough, ON K9J 8S1.

This information is collected under the legal authority of the Municipal Act, 2001, sections 9 and 10, and the City of Peterborough By-law 14-147, for the purpose of administering Housing Stability Fund benefits and evaluating the program.

For more information contact: Social Service Program Manager, 178 Charlotte Street PO Box 4138 Peterborough , ON K9J 8S1 tel: 705-748-8830 socialservices@peterborough.ca