Application for: Assistance under the Ontario Works Act / Income

0983 (2013/01)

français 0354 7730-0983

Turn Over

Page 1 of 4

D M Y

DM Y

Ministry of Community

and Social Services

Application for

Assistance under the Ontario Works Act

Income Support under the Ontario

Disability Support Program Act

Application Update Report

Part 1: Financial Assistance

Has the applicant previously applied for assistance under the Ontario Works Act, 1997, for beneﬁts under the Family Beneﬁts Act, or

support under the Ontario Disability Support Program Act, 1997?

Yes

OW FBA/ODSP

Location

Date of Last Assistance

Amount

As an Ontario Works applicant or recipient, have you ever had your assets assessed at the higher ODSP asset level?

No Yes

1. Case Class

Ontario Works Act

Single (18 and over)

Couple

Under 18 Years of Age

Sole Support

Disabled

Aged

Other, provide details

Ontario Disability Support Program

Disabled

Prescribed, provide details

2. Applicant

Mr.

Mrs.

Ms.

Miss

Single

Married

Spousal

Widowed

Divorced

Separated

Last Name First Name Initials

Date of Birth

Other/Previous Name T

elephone No. (Including Area Code)

Street Number Unit/Suite/Apt. Street Name

City/Town/Municipality Province Postal Code

Social Insurance No. Health No. Version Education - Highest Level

Next of Kin Relationship Address

3. Dependants: List all dependants including spouse, dependent children and dependent adults living with you.

Spouse

Spouse’s Last Name First Name Other Name

Social Insurance No. Health No. Version Date of Birth

Education - Highest Level

Dependent Child(ren) (up to 18 years old) living with you - Name(s) on birth certiﬁcate(s)

Last Name First Name

Date of Birth

School Name Grade Health No. Version

Last Name First Name Date of Birth

School Name Grade Health No. V

ersion

Last Name First Name Date of Birth

School Name Grade Health No. V

ersion

Dependent Adult(s) (18 and over) living with you - Name(s) on birth certiﬁcate(s)

Last Name First Name Other Name

Social Insurance No. Health No. Version Date of Birth

Education - Highest Level School Name Grade

Last Name First Name Other Name

Social Insurance No. Health No. V

ersion Date of Birth

Education - Highest Level School Name Grade

Do you have any dependants not living with you?

No Yes, provide details in Section 15

Is any other person using this address for any other reason?

Yes, provide the following:

Name

Reason Relationship

0983 (2013/01) français 0354 Page 2 of 4 7730-0983

Turn to BACK to begin on Page 1

D MY

DM Y

4. Living Conditions

Are you living with your parent(s) or the parent(s) of your spouse?

No Yes

If “Yes”, is/are your parent(s)

in receipt of ODSP/OW in receipt of GIS or Gains?

If you are a sponsored immigrant, do you live with your sponsor ?

No Yes

If “Yes”, is your sponsor

in receipt of ODSP/OW

in receipt of GIS or Gains?

Boarding

(Room & meals

provided)

Monthly Amount

Veriﬁed

With Whom

Relationship Effective Date

Renting

subsidized

unsubsidized

Own Home/

Condominium

Monthly

Amount

V ﬁeri ed

Mortgage Balance

Veriﬁed

Condo. Fees

Veriﬁed

Landlord/Mortgage Holder

Address Telephone No.

Property Taxes (Annual)

Veriﬁed

Insurance (Annual)

Veriﬁed

Utilities (Monthly)

Veriﬁed

Heating Costs (Monthly)

Verifﬁed

Equal Billing

Yes No

Do you pay the total

accommodation costs?

Yes No; If “No”

Amount paid by you Amount paid by cores. No. of sharers

Effective Date

Are you, your spouse or dependant in a hospital, nursing home or other institution?

No Y

es; If “Yes”, provide the following:

A / S / D

Name and Address of Institution

Date of Admission

Expected Date of Discharge

5. Income

Received

A S D

Description Monthly Amount

Veriﬁed

YN YN

OAS / GIS / SA / Allowance for the

Survivor Program

GAINS A

Annuities, Superan, Insur. Ben.,

Seg. Funds

Earned Interest

Canada Pension Plan, QPP

Pension Act (Canada)

War Veterans’ Allowance

Employment Insurance

Foreign Pensions / U.S. Soc. Sec.

W.S.I.B.

Comp. for Victims of Crime

Children’s Lawyer / Public Guardian

and Trustee

Trust

Mortgage Rec./Loan Agreement

Farm or Business

Rental

housing

garage

land

other

Support Payments

Loans

Other

6. Current Earnings/

Training

Monthly Amounts

Veriﬁed

Child Care Exp.

Type

Veriﬁed

Work Related

Exp. (Disabled)

Veriﬁed

Gross Code Net

N Y

Applicant

Spouse

Dependant

7. When were you, your spouse or dependant last employed?

Date Last Employed Reason for Leaving EI Eligibility Date EI Status

Own

Trans

Reason

Unempl.

Length

of Empl.

Propd.

Act.

D MY D MY

8. Do you have a

Roomer or Boarder?

No Yes

R/B

Effective Date

Name Relationship Amount

DM Y

Is any Roomer or Boarder your child, grandchild, child in temporary care of you or your spouse?

No Yes; If “Yes”, are they

in receipt of ODSP

in receipt of Ontario Works

attending an educational institution without ﬁnancial assistance?

Provide details in Section 15

Is any other person living in the home? (eg. landlord)

No Yes; If “ Yes”, provide the following:

Name Relationship - provide details in Section 15

0983 (2013/01) français 0354 Page 3 of 4 7730-0983

9. Assets

Personal Property

YNASD

Details Value $

Veriﬁed

Y N

Cash on Hand

Chequing / Savings Accounts

(Banks, Trust Companies, Credit Unions)

Investments

(Bonds, Shares, RRSP, RESP, Term

Deposit)

Life Insurance

(Cash Surrender Value,

Annuities,

Superan, Insur. Ben., Seg. Funds)

Receivables

(Mortgages, Loans,

Accounts Receivable)

Vehicles

Safety Deposit Box

Valuables

(Coins, Stamps, Jewellery)

Prepaid Funeral

(Amount in Excess of Allowable Exemption)

Beneﬁcial Interest in Assets Held in Trust

(Children’s Lawyer / Public Guardian and

Trustee)

Trust

Acquired by Inheritance

s No

Financial Interest in Business

Other

I hereby authorize direct deposit into - Direct Bank Deposit

Branch Institution Account Number

Real Property - other than Principal Residence?

No Yes; If “Yes”, provide the following:

Lot and Plan/

Concession

Address

ASD

Owned or

Life Tenancy

Rented

Vacant

Occupied

Year

Purchased

Current Market

Value $

Equity

Veriﬁed

Y N

Have you, your spouse or any dependant disposed of any assets (personal or real property) within the last twelve months or since the last report?

No Yes; If “Yes”, provide details:

Are any assets expected in the future by you, your spouse, or any dependants?

No Yes; If “Yes”, provide details:

10. Other Financial Resources

Are there any other f nancial resources/income to which the applicant/spouse or dependent child(ren)/dependent adult may be entitled?

Yes; If “Yes”, provide the following:

Name Address For (Name) Amount $

Sponsorship

Support

Ontario Child Beneﬁt

National Child Beneﬁt Supplement

OSAP

Other - specify

Has an application been made for any types of income for which the applicant/spouse or dependent child(ren)/dependent adult may be eligible?

No Yes; If “Yes”, provide details:

Previous Spousal Relationship Applicant

Yes, provide details in Section 15

Spouse/

Dep. Adult

Yes, provide details in Section 15

11. Special Items

Are any of the following items required by you, your spouse or any dependant?

No Yes

Special Diet Transition Child Beneﬁt Guide Dog Allowance

Pregnancy Nutritional Allowance

Travel/Transportation

12. Status in Canada

If born outside Canada, provide the following:

Arrival Date

Veriﬁed

Current Status

Veriﬁed

Landing Date

Applicant

Spouse

Dependant(s)

13. Residence

List all places of applicant’s residence within the last 12 months (OW only).

From (month/year)

To (month/year)

Address

Municipality

Province

0983 (2013/01) français 0354 Page 4 of 4 7730-0983

14. Update Report Only

Have you or your spouse or any dependant been absent from Ontario?

No Yes; If “Yes”, provide details:

Did you receive Social Assistance from any other province/state/country while absent from Ontario?

No Yes; If “Yes”, provide details:

Have you or your spouse or your dependant been in hospital, nursing home, detention centre or other institution?

No Yes; If “Yes”, provide the following:

Name

Name and Address of Institution

Date Entered Date Released

15. Additional Information (e.g. Health numbers for dependent children or adults, debts)

For OW Applicants, this application has been assessed at the higher asset level for ODSP.

No Yes

Note: You are responsible for following the rules of the Ontario Works Program/Ontario Disability Support Program, including honest

reporting of all changes in your income, assets and living arrangements.

The Criminal Code of Canada s.s. 380 (1) states that everyone who by deceit, falsehood or other fraudulent means defrauds the public of

any property, money or valuable security, is guilty of an offence. The Ontario Works Act, 1997, Sec. 79/Ontario Disability Support Program

Act, 1997, Sec. 59, states that a person who knowingly obtains or receives a beneﬁt/assistance that he/she is not entitled to obtain or receive

under the Act and the regulations is guilty of an offence.

If there is sufﬁcient evidence to suspect that fraud, or an offence under social assistance legislation has been committed, the matter may be

referred to the police for investigation.

16. Statutory Declaration (complete spousal information if applicable)

1. I,

(full name)

do solemnly declare that I am the Applicant/Recipient (or the person

applying on behalf of the Applicant/Recipient) named in this application.

(full name)

do solemnly declare that I am the spouse of the above mentioned

Applicant/Recipient named in this application.

3. I/we,

(full name(s))

do solemnly declare that

I am/we are the Dependent Audlt(s) of the above mentioned Applicant/Recipient named in this application.

I/W

e have been interviewed by the Ontario Works Administrator or his/her representative or by the Director of the Ontario Disability

Support Program Branch of the Ministry of Community and Social Services or his/her representative. I/We understand the eligibility

criteria. I/We have supplied the information in this application to the best of my/our knowledge and belief. All statements are true and no

information required to be given has been withheld or omitted.

5. For purposes of Ontario Works only, I/we acknowledge that I/we have completed Part 2 of this application and have been provided with a

copy.

6. Should assistance be granted or continued on the basis of the information in this application, I/we will notify the administrator, the Director,

or his/her representative as the case may be, of any change of circumstances relevant to the assistance provided to me or on my behalf,

including any change in circumstances pertaining to my/our assets, income, dependants, living arrangements and participation in Ontario

Works activities as set out in the participation agreement(s).

I/we acknowledge that the information contained in this application may be used for the purpose of applying for and/or verifying eligibility

for assistance under the Ontario Works Act, 1997 or the Ontario Disability Support Program Act, 1997 and I/we undertake to provide any

additional information that may be requested at that time.

8. I/We make this solemn Declaration conscientiously believing it to be true and knowing that it has the same force and effect as if made under

oath by virtue of the Canada Evidence Act.

Declared before me at the

in the of

this day of

Signature/mark of applicant/recipient or

person applying on behalf of applicant/recipient

Signature/mark of spouse where applicable

A Commissioner etc.

Notice with Respect to the Collection of Personal Information

(Freedom of Information and Protection of Privacy Act)

(Municipal Freedom of Information and Protection of Privacy Act)

This information is collected under the legal authority of the Ontario Disability Support Program Act, 1997, sections 5 & 10, 45 & 46 or the

Ontario Works Act, 1997, sections 7, 8, 15, 57 & 58 for the purpose of:

• administering Government of Ontario social assistance programs. For more information contact

at ( ) , in your local Ontario Works or ODSP ofﬁce.

• administering payment of prescription drug claims and conducting drug use review for the Ontario Drug Beneﬁts Program. For more

information contact: the Director, Drug Programs Branch, 5700 Yonge Street, 3

Floor, Toronto ON M2M 4K5.

For Ofﬁce Use Only Forms, documents, certiﬁcates to follow (specify):