V-10-xxx 2016/03
ODSP Discretionary Benefit
Request Form
Notice of Collection
(Municipal Freedom of Information Act)
The personal information on this form is collected under the authority of the Municipal Act, 2001 S.O. 2001, s. 11 and will be used to verify,
administer and report on the results of the Peel Renovates - Homeowner Renovation Assistance Program Application. Questions about this
collection should be addressed to the Supervisor, Community Access, Human Services at 10 Peel Centre Dr., Suite B, PO Box 2700, STN B,
Brampton ON L6T 0E6 or at 905-793-9200.
V-10-700 2019/05
Notice of Collection (Municipal Freedom of Information Act)
This information is collected under the authority of the Ontario Works Act. The information will be used to support the issuance of
discretionary benefits which are provided only to benefit unit members who meet the eligibility criteria. Questions about this collection
should be addressed to the Supervisor, Community Access, Human Services at 10 Peel Centre Dr., Suite B, PO Box 2700, STN B, Brampton
ON L6T 0E6 or at 905-791-7800.
Please fax completed form along with supporting documents to 905-793-4833
ADDRESS
CITY
PROV. POSTAL CODE
ITEM REQUESTED
PLEASE REMEMBER TO ATTACH ALL VERIFICATION DOCUMENTS
E-MAIL ADDRESS
NAME (Please Print)
PHONE NUMBER (Working Number Please)
ALTERNATE PHONE NUMBER
Other (Please attach verification documents and specify request):
Dentures (Estimates not required at this time)
CLIENT INFORMATION
For more information please call 905-791-7800
Please note your request will not be processed without relevant verification/estimates attached.
Items will not be reimbursed.
Medical Equipment (Please attach occupational therapist/doctor's referral)
Vision Care (For ODSP dependent adults)
Items will not be reimbursed and will not be processed without estimates attached
DATE
Member ID
