Dec 6 Fund- YWCA Halifax - Application Form (2024)

December 6th Microloan Application
The December 6th Microloan Program offers no-interest bearing microloans of up to $500 for housing-related costs for women, Two-Spirit, and Gender Diverse individuals who have fled or experienced gender-based violence within the last 12 months. These housing-related expenses can include damage deposits, rent/mortgage payments, utility payments/arrears, storage costs, and phone/internet payments.

To access the December 6th Microloan Program you must meet the following eligibility criteria:

- Have fled or experienced gender-based violence within the last 12 months.

- Currently reside in Nova Scotia, or have fled Nova Scotia within the last 12 months.

- Must be 18 years of age or older at time of application.

- Must have your own bank account, or be willing to open one during the application process.

Due to a high volume of applications, it can take 3-4 business days for the December 6th Team to respond to your request. We appreciate your patience.

Please Note: This program does not offer case management outside of the loan process. The December 6th team provides short-term, solution-focused support related to the loan application process for a maximum of six weeks.
Have you fled or experienced gender-based violence within the last 12 months?*

YesNo
Referral Source
First Name *
Last Name *
Alias/Preferred Name
Date of Birth*

MonthDayYear
Date
Contact Phone Number*
Is it safe to leave messages on your phone?*

YesNo
Contact Email Address*
Safe Methods of Contact (please select all that apply)*

CallEmailText
Gender Identification*

FemaleTransNon-BinaryTwo-SpiritMaleOther
Preferred Pronouns*

She/HerHe/HimThey/ThemOther
Racial Identification

WhiteBlackIndigenousArabicAsianEast IndianAfricanLatinoOther
Citizenship Status*

Canadian BornCanadian NaturalizedPermanent ResidentRefugeeOther
Do you currently live in Nova Scotia?*

YesNo
If you're not currently living in Nova Scotia, have you left the province within the last 12 months as a result of gender-based violence?

YesNoNot Applicable (currently living in Nova Scotia)
Which community do you live in?*
What best describes your housing situation?*

Live AloneRoommatesWith PartnerWith family or friendsShelter2nd Stage HousingUnhousedOther
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Address (if different)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you currently employed?*

Employed Full-TimeEmployed Part-TimeSelf- EmployedSeasonally EmployedUnderemployedUnemployed by choiceUnemployed b/c of disabilityUnemployed
What is your monthly income, excluding Child Tax Benefit and GST Benefit?*
What are your financial resources?*

EmploymentESIACPP (OAS or Disability)EIChild SupportChild Tax BenefitPartner's IncomeOther
What is your highest level of education completed?*

No High SchoolHigh School/GEDDiplomaBachelorMasterPh.DPrivate CollegeOther
Relationship Status*

Married or Common-lawRelationship (not living together)Divorced, Separated or WidowedSingleOther
Do you have any no contact or protection orders with any of your current or former partners?*

YesNo
If you do not currently have any protection orders with your current or former partner, are you interested in information about how to get one?*

YesNo
Do you have dependent children?*

Yes, live with meYes, don't live with meYes, in temporary careYes, in permanent careChildren are adult(s)No children
Please provide an emergency contact: *
Name
Relationship to you*
Phone Number*
What are you hoping to use the December 6th microloan for?*

Damage DepositRent/Mortgage PaymentUtility Bill/ArrearsStorage CostsPhone Bill Payment/ArrearsInternet Bill Payment/Arrears
Do you have your own bank account?*

YesNo
The December 6th Program offers resource navigation for individuals seeking additional supports outside of our program. To access this navigation service, a phone call or in-person appointment is required.
Other Support/Program Needs (please check a maximum of three)

HousingService NavigationEducationParenting supportExiting TraffickingChildcareLegal SupportWomen's HealthcareGender Affirming HealthcareFood supportSafety PlanningMental Health SupportsSubstance Use Supports (Harm Reduction, Recovery)Sex Worker SupportsOther
Your confidentiality is important to us. If you require additional services within, or beyond the scope of Dec 6 and would like YWCA Halifax to contact other programs and services on your behalf. Please sign this consent form. We will consult with you on what information can and cannot be shared before communication of personal information to any service provider. You may revoke consent at any time. Disclosure of data and personal information will be limited to individual consent gained or in the case of subpoena or legally required disclosure such as the Duty to Report.
I, (Print your name)
Authorize December 6th Program Staff, to disclose my information pertaining to my case file for the purposes of case management and service provision to the following agencies and individuals:

Other YWCA Staff/ProgramsMy LandlordUtility CompanyIncome AssistanceLawyers/Legal AidParole/Probation OfficerOther Non-Profit AgencyOther
Please provide the contact information (Program Name/Contact Person Name, Email Address & Phone Number) for options check-marked above.
YWCA Halifax will be entering your data into a secure database and may use anonymous and de-personalized data collected on this form for the purposes of research. program planning, policy development and/or organizational strategic planning. This means you will not be identifiable and your comments will be kept confidential. This information is sometimes required by funders to evaluate the effectiveness of the program, and will assist us in serving you, and all of our participants better. YWCA Halifax will collect and store electronic data on for the purposes of:

a. Case management
b. Program coordination and development
c. Statistical reporting
d. Research
e. Program evaluations
f. Funder compliance
g. Fund development
h. Partnership development
i. Payroll
j. Emergency contact
k. Human resources

No data or personal information will be collected or stored which falls outside any of these stated purposes. YWCA Halifax will limitthe use of data and personal information to the purposes stated above. YWCA Halifax will retain data and personal information for no longer than 7 years.
I, (Print Name) *
Authorize YWCA Halifax to

Enter this information into their client database; use non-identifiable data for internal planning purposes; use non-identifiable data for research and evaluation purposes; contact me for opportunities to participate in research
Client signature*

Clear
Should be Empty:

December 6th Microloan Application