Request for OW or ODSP Information

Name of Tenant / Date of Birth
Address and Unit # / City/Town
Name of Housing Provider
Contact Name and Title
Please have your OW/ODSP Caseworker complete this section
The above named person is in receipt of:
Ontario Works / Ontario Disability Support Plan
Single person without beneficiaries / Grant Date:
Couple with/without beneficiaries / # of beneficiaries (including recipient)
Single person with beneficiaries
Please list all members in the benefit unit:
Please complete the following information based on the most recent assistance provided
Benefits: / Amount $ / Deductions: / Amount $ / Period Covered
Shelter / Support Income
Basic Income Support / Other -specify
Other - specify / Cheque Amount $
Total Benefits / Total Deductions
Does anyone else live in the unit? / Yes, please explain / No
Name of Caseworker: / Contact Number:
Signature: / Date:

Notice with respect to the Collection of Personal Information

This information is collected under the legal authority of the Housing Services Act, 2011 for the purpose of administering the social housing programs prescribed in the Act and its Regulations. For more information contact the Privacy Officer at 905-825-6000.