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Social

Benefits

Tribunal

Appeal Form

Questions?

Toronto:

(416) 326­0978

Outside Toronto: 1­800­753­3895

Fax:

(416) 326­5135

Mail to: Registrar

Social Benefits Tribunal 1075 Bay Street, 7th Floor Toronto ON

M5S 2B1

Please attach copies of the following to this form:

•the original Notice of

Decision

•your request for an internal review and

•the Internal review decision (if you received one).

Disponible en français.

Office Use Only

File number

Date post­marked

Before you can appeal to the Tribunal, you must request an internal review by the office that made the original decision.

1. General Information

Mr

Mrs

Ms

Miss

Last Name

First Name

Address

				Apartment
City			Postal Code
Telephone (		)

•When were you born?

	/	/
Day	/ Month	/Year

•Which Ontario Works or Ontario Disability office do you deal with? Office name

Office address

Case worker's name

Case worker's telephone (		)

2. Internal Review

•What is the date of your Notice of Decision?

	/	/
Day	/ Month	/Year

•When did you make your request for an internal review?

	/	/
Day	/ Month	/Year

•Did you receive an internal review decision?

Yes

No

Important: If you do not attend your hearing and fail to provide a reasonable explanation for you absence, your appeal will be denied. In addition, you will not be allowed to appeal a subsequent decision on the same issue for two years.

The Social Benefits Tribunal does not have the authority to review all social assistance decisions. We will advise you in writing of the reasons if your appeal cannot be heard.

You must file your appeal within 30 days of the end of the internal review period. If you do not do so, you must explain why you were late filing. The Tribunal may extend the time for filing this appeal, if it is satisfied that there is a reasonable explanation for the delay.

3. Your Reasons for Appealing

•What are you appealing? Ontario Works

Ontario Disability Support Program (disability, seniors or children with severe disabilities).

•Why are you appealing? Check all the boxes that apply to you.

I was refused assistance.	My assistance has been cancelled.
My assistance has been reduced.	My assistance is on hold.
I have an overpayment.	They say I am not disabled.
The amount of my assistance is wrong.

•What is the effective date of the decision you are appealing?

	/	/
Day	/ Month	/Year

•You must explain what you disagree with in the original decision and why. Use the space below and attach additional pages if necessary.

Interim assistance is financial help you may be eligible to receive while waiting for your appeal to be concluded.

The Tribunal may order that you receive interim assistance if you will experience financial hardship as a result of the original decision made by your local office. To assess your request for interim assistance, the Tribunal requires detailed financial information.

You will be notified in writing of the Tribunal's decision regarding interim assistance.

Note: If you lose your appeal, your interim assistance shall be assessed as an overpayment.

4. Application for Interim Assistance

•Describe your household. How many people, including yourself, have you applied on behalf of?

adults

children

•Check the box beside those sentences that best describe you situation.

I am looking for work.

I am in an employment assistance program.

I am attending school	full­time		part­time
	high school		college	university	other.
I am under 18 and cannot live at home.
I am working, but earn less than the Ontario Works entitlement.
• Are you receiving any money at all?		Yes	No

•If you live with your spouse/same­sex partner, is he/she receiving any money?

Yes

No

•If you or your spouse/same­sex partner are receiving money, please provide details of your household income below. Include the amount you receive, when you last received it and how often you receive this income.