Disponible en français2878E (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 français

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 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.

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 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.

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.: