statement of Income

Unless you have been told otherwise, you have two options: Attach your paystubs and receipts OR Fill in the information below and
keep your pavstubs and receipts in case we ask to see them in the future. ________________ ____________ ____________ ______
Name Member ID Office ID Case Owner Income Change
QYES QNO

MAIL THIS FORM TO THE ADDRESS BELOW AS SOON AS POSSIBLE ARER DAY MORN YEAR INCOME FOR DAY MORH YEAR TO DAY MONTH YEAR

Have LH you dl your spouse LH dep. adult

r~| stopped LH started working this month?
Name of Employer or Paid Training Program

Date of LH last d] first pay cheque

Earnings
1. Complete payment Information for each family member who is employed or in a paid training program
2. If applicable, enter any deductions
Employer Name/ Employer Name/ Employer Name/ Employer Name/ Employer Name/
Training Program Training Program Training Program Training Program Training Program
Name;
1 1 Recipient L3 Spouse LH Dep. Adult

Attending secondary/post-secondary
school full time? [j No LH Yes Date Date Date Date Date
Amount Amount Amount Amount Amount
Gross pay (before deductions)
Net pay (after deductions)

Deductions (enter only if appiicable)

Child or spousal support payments

Other garnishments to repay a debt
Employer Name/ Employer Name/ Employer Name/ Employer Name/ Employer Name/
Training Program Training Program Training Program Training Program Training Program
Name:
1 1 Recipient LH Spouse []] Dep, Adult

Attending secondary/post-secondary
school full time? Q No Q Yes Date Date Date Date Date
Amount Amount Amount Amount Amount
Gross pay (before deductions)
Net pay (after deductions)

Deductions (enter only if applicable)

Child or spousal support payments

Other garnishments to repay a debt

Child Care Expenses

1. Enter the child name and child care provider name
2. Select the type of child care, licensed (most day cares) or unlicensed (most babysitters) and enter the amount

Child name Child care provider name Licensed Unlicensed Amount

□ □ □

□ □ □

I declare the information here to be accurate and complete. Signature (Recipient/Trustee) Date

Notice with Respect to the Coiiection of Personai 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, please contact your caseworker at your local Ontario Works office. For local office contact information, please contact ServiceOntarlo
toll-free at 1-888-789-4199 (TTY: 1-800-387-5559) or visit the ministry’s website at www.ontario.ca/mcss.
 Changes Report
COMPLETE ONLY IF THERE ARE CHANGES TO REPORT and return to your local office BY THE 16th of the month: ATTACH RECEIPTS.
It is your legal obligation to report CHANGES in living arrangements, shelter costs, family size, income or assets.
Name Member ID Office ID Case Owner Changes for the month of

Have you moved?

Date Moved Q Renting []] Boarding (meals) Q Own Home Q Institution/Hospital

New Address
Street Number Street Name Unit Number

□ POBox
T own/Citv ....
l~l Rural Route
I I General Delivery P nstal Code New Phone Numb ar

Do you have new housing costs? Attach receipts for new housing expenses.
Amount Paid Start Date (D/M/Y/)
New Rent/Boarding/Mortgage Amount

New Monthly Utility Costs (e.g. Hydro, Insurance)

New Annual Heating Costs Q Oil Q Gas Q Electric [] Wood

Family Changes
Name
n Recipient I I Spouse n Dep. Adult I I Dep. Child

Details of change: (e.g. moved out, finished school, new baby) Start Date (D/MA'Z)

Is a family member leaving Ontario for more than 7 days? Date leavin a Df te returning

Name
|~| Recipient I I Spouse I I Dep. Adult I I Dep. Child

Does any family member have changes in assets (bought or sold or changed in value)?

Type of Asset New Value Start Date (D/M/Y/)

Other Changes in Circumstances (e.g. shared custody, new person living with you)

Does any family member have changes in income?

Amount Amount
Gross Income Gross Income
Recipient Spouse Dep. Recipient Spouse Dep.

Support Payments Rental Income

Employment Insurance Foreign Pension

WSIB Private Pension

CPP/QPP - Retirement Gifts / Windfalls

CPP/QPP - Disability Loans

CPP/QPP - Survivor Trust / Inheritance

OAS/QIS Segregated Funds / Annuities

GAINS A Interest / Dividends

Roomer Income Insurance Benefits

Boarder Income Other (specify):

I declare the information here to be accurate and complete and Signature (Recipient/Trustee) Date
agree to advise my local Ontario Works office of any changes.