request for internal review - ontario for internal review ... where to send form. 1. ... you must...
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Disponible en franais2878E (2013/09) Queen's Printer for Ontario, 2013 7730-2878
Ministry of Community and Social Services
Ontario Disability Support Program
Request for Internal Review
Instructions Please print clearly Where to send form
1. Look at the letter that told you about the decision you disagree with.2. Mail or fax it to the address that appears at the top of the letter.
Last Name First Name
Member I.D. (9-digit)Date of Birth (dd/mm/yyyy)
What type of decision do you want reviewed?My application for income support was denied
My income support has been stopped
My income support has been reduced
An overpayment has been set up on my case
I was refused an additional benefit or I disagree with the amount provided
I disagree with a decision made by the Disability Adjudication UnitMy ODSP Employment Supports file was put on hold or closedI have been deemed ineligible for ODSP Employment Supports
Other (explain)
What is the date on the letter that told you about the decision? (dd/mm/yyyy)
Why do you disagree with the decision? (optional) If you have information that you think will help with the review, please explain it here and attach any documents to this form (e.g., receipts, additional medical information, etc.)
You must request an internal review within 30 days of receiving the decision letter. If more than 30 days have passed, please explain why you needed more time. If the reason your request was late was for reasons beyond your control, we may do an internal review even if the deadline has passed.
Signature Date (dd/mm/yyyy)
Notice with Respect to the Collection of Personal Information (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, 32, 33, 36, 45 & 46 for the purpose of administering Government of Ontario social assistance programs.
For more information contact at ( )in your local ODSP office.
Disponible en franais
Also available in English
2878E (2013/09) Queen's Printer for Ontario, 2013
7730-2878
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Government of Ontario
Ministry of Community
and Social Services
Ontario DisabilitySupport Program
Request for Internal Review
Instructions
Please print clearly
Where to send form
1. Look at the letter that told you about the decision you disagree with.
2. Mail or fax it to the address that appears at the top of the letter.
What type of decision do you want reviewed?
Notice with Respect to the Collection of Personal Information (Freedom of Information and Protection of Privacy Act)
This information is collected under the legal authority of theOntario Disability Support Program Act, 1997, sections 5, 10, 32, 33, 36, 45 & 46 for the purpose of administering Government of Ontario social assistance programs.
at
( )
in your local ODSP office.
9.0.0.2.20101008.1.734229
Request for Internal Review
Ministry of Community and Social Services
Ministry of Community and Social Services
Request for Internal Review
Clear Form: Print Form: Last Name: First Name: Member I.D. (9-digit): Signature. Date. Enter date in format: day: 2 digits, month: 2 digits, year: 4 digits. Or select date from the drop down calendar.: What type of decision do you want reviewed? My application for income support was denied: 0What type of decision do you want reviewed? My income support has been stopped: 0What type of decision do you want reviewed? My income support has been reduced: 0What type of decision do you want reviewed? An overpayment has been set up on my case: 0What type of decision do you want reviewed? I was refused an additional benefit or I disagree with the amount provided: 0What type of decision do you want reviewed? I disagree with a decision made by the DisabilityAdjudication Unit: 0What type of decision do you want reviewed? My ODSP Employment Supports file was put on hold or closed: 0What type of decision do you want reviewed? I have been deemed ineligible for ODSP Employment Supports: 0What type of decision do you want reviewed? Other: 0What type of decision do you want reviewed? Other (explain). : Why do you disagree with the decision? (optional) If you have information that you think will help with the review, please explain it here and attach any documents to this form (e.g., receipts, additional medical information, etc.): You must request an internal review within 30 days of receiving the decision letter. If more than 30 days have passed,please explain why you needed more time. If the reason your request was late was for reasons beyond your control,we may do an internal review even if the deadline has passed.: Signature: Notice with Respect to the Collection of Personal Information (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, 32, 33, 36, 45 & 46 for the purpose of administering Government of Ontario social assistance programs. For more information contact : at (enter telephone number) in your local ODSP office.: