PANIER DE NOËL – Coopération Intégration Canada

Christmas basket

Vous habitez à Ottawa et vous souhaitez bénéficier d’un panier de Noël gratuit ou d’un chèque cadeau échangeable ? Ce programme est pour vous !

Contactez-nous avant et remplissez le formulaire au plus tard le 19 novembre 2024 à 23h59. Nous serons heureux de vous servir !

Program funded by:

This program is only open during Christmas

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First Name *

Last Name *

Date de naissance *

Votre Sexe? *

Masculin
Féminin
other

Phone Number *

Email *

Preferred communication language *

French
English

Are you covered by the low income threshold standard? Check the box that corresponds to the range of your annual income, based on the size of your family *

1 person in the family? After-tax family income less than or equal to $24,347
2 persons in family? Family income after taxes less than or equal to $29,632
3 persons as a family? After-tax family income less than or equal to $36,898
4 persons in family? Family income after taxes less than or equal to $29,632
5 persons as a family? After-tax family income less than or equal to $52,418
6 persons in your family? After-tax family income less than or equal to $58,133
7 persons or more as a family? After-tax family income less than or equal to $63,848

Is the client's address a co-op or apartment building? *

If yes, please enter the alarm or bell number here:

Is it a shelter or a shared apartment? *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Does the client have a spouse or partner? *

If yes, please enter their email

Last Name

If yes, please enter their phone number

Number of Kids (0 to 17 years old) *

Please enter the name(s), gender(s) and age(s) of all children in the household

Number of adults (18 to 54 years) *

Please enter the name(s), gender(s) and age(ies) of all seniors in the household: (If applicable – Include the client listed in the primary information section):

Total number of seniors (55 years and over) *

Please enter the name(s), gender(s) and age(ies) of all seniors in the household: (If applicable – Include the client listed in the primary information section):

partagé? ans ménage

Other information: