Form 1 "Appeal" - Ontario, Canada

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Instructions for Filing an Appeal: Form 1
1. Before you can appeal to the SBT you must request an internal review by the Ontario Disability
Support Program (ODSP) or Ontario Works (OW) office that made the decision. The SBT does not
decide internal reviews. You must file your appeal with the SBT within 30 days of receiving the
internal review decision. If you are late filing you need to explain why. The SBT will decide whether to
allow a late appeal.
2. Attach copies of the following to this form:
i) the original Notice of Decision from the OW or ODSP office
ii) your request for an internal review from the OW or ODSP office
iii) the internal review decision (if you received one).
3. The SBT does not have the authority to review all social assistance decisions. If we can’t hear your
appeal, we will send you a letter with the reasons why.
4. If you are experiencing financial hardship while you wait for your appeal to be decided you can ask
the SBT for interim assistance by completing Part 5 of this form. Interim assistance is financial help
while waiting for your appeal to be decided. If the SBT decides you are eligible for interim assistance,
you will be notified in writing. If you lose your appeal, your interim assistance shall be assessed as an
overpayment and you may have to pay it back.
Note: The SBT does not issue cheques. Your local ODSP or OW office will pay the interim assistance.
5. If you do not attend your hearing and don't provide a reasonable explanation for your absence, your
appeal will be denied and you will not be allowed to appeal a subsequent decision on the same issue
for two years except in certain circumstances. For more information, visit our website at
tribunalsontario.ca/sbt
or phone the SBT at one of the numbers below:
Tel:
416-326-0978
Toll-free: 1-800-753-3895
TTY:
Call the Bell Relay Service at 1-800-855-0511
Social Benefits Tribunal ● 15 Grosvenor Street, Ground Floor, Toronto, ON M7A 2G6 ● Fax 416-326-5135
Instructions for Filing an Appeal: Form 1
1. Before you can appeal to the SBT you must request an internal review by the Ontario Disability
Support Program (ODSP) or Ontario Works (OW) office that made the decision. The SBT does not
decide internal reviews. You must file your appeal with the SBT within 30 days of receiving the
internal review decision. If you are late filing you need to explain why. The SBT will decide whether to
allow a late appeal.
2. Attach copies of the following to this form:
i) the original Notice of Decision from the OW or ODSP office
ii) your request for an internal review from the OW or ODSP office
iii) the internal review decision (if you received one).
3. The SBT does not have the authority to review all social assistance decisions. If we can’t hear your
appeal, we will send you a letter with the reasons why.
4. If you are experiencing financial hardship while you wait for your appeal to be decided you can ask
the SBT for interim assistance by completing Part 5 of this form. Interim assistance is financial help
while waiting for your appeal to be decided. If the SBT decides you are eligible for interim assistance,
you will be notified in writing. If you lose your appeal, your interim assistance shall be assessed as an
overpayment and you may have to pay it back.
Note: The SBT does not issue cheques. Your local ODSP or OW office will pay the interim assistance.
5. If you do not attend your hearing and don't provide a reasonable explanation for your absence, your
appeal will be denied and you will not be allowed to appeal a subsequent decision on the same issue
for two years except in certain circumstances. For more information, visit our website at
tribunalsontario.ca/sbt
or phone the SBT at one of the numbers below:
Tel:
416-326-0978
Toll-free: 1-800-753-3895
TTY:
Call the Bell Relay Service at 1-800-855-0511
Social Benefits Tribunal ● 15 Grosvenor Street, Ground Floor, Toronto, ON M7A 2G6 ● Fax 416-326-5135
Appeal
FORM 1
-
File Number:
(Office use only)
Part 1: General Information
Appellant's Name:
Appellant's date of birth:
Address:
Unit Number:
PO Box:
Municipality (City, town):
Province:
Postal Code:
Telephone 1:
Telephone 2:
Which office made the decision you are appealing?
Ontario Works office
Disability Adjudication Unit
Ontario Disability Support Program office
Member / Case ID:
Office name:
Office address:
Case worker's name:
Case worker's telephone:
Part 2: Internal Review Information
If you did not request an internal review, you may not appeal to the SBT.
What is the date of your original Notice of Decision?
/
/
dd/mm/yyyy
When did you make your request for an internal review?
/
/
dd/mm/yyyy
Did you receive an internal review decision?
Yes
No
Part 3: Your Appeal
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.
They say I am no longer disabled, as a result of a
The amount of my assistance is wrong.
medical review.
Social Benefits Tribunal ● 15 Grosvenor Street, Ground Floor, Toronto, ON M7A 2G6 ● Fax 416-326-5135
Page 1 of 4
Explain what you disagree with in the original decision and why. Use the space below and attach additional pages
if necessary.
Part 4: Your Hearing
Your hearing will be scheduled by video conference. You are required to provide your email address for
scheduling purposes only:
Email Address (please print clearly):
If you CANNOT attend a video conference, please explain why. The SBT may schedule a hearing in a different
format if necessary.
In what language would you like your hearing?
English
French
Will you need any of the following services at the
Physical or other accommodation to participate in the
hearing?
hearing. Please specify.
Interpreter:
Language
Dialect
Sign language interpreter
Signature:
Name:
Signature:
Date:
Collecting Personal Information: The Social Benefits Tribunal (SBT)
collects the personal information requested on this form under the Ontario
Works Act, 1997 or the Ontario Disability Support Program Act, 1997. It will
be used for the purpose of conducting the appeal and will be shared with the
parties. If you have any questions, contact the SBT at 1-800-753-3895.
v. 08/2021
This completes the appeal section.
If you are experiencing financial hardship, complete Part 5 Application for Interim Assistance.
Social Benefits Tribunal ● 15 Grosvenor Street, Ground Floor, Toronto, ON M7A 2G6 ● Fax 416-326-5135
Social Benefits Tribunal ● 15 Grosvenor Street, Ground Floor, Toronto, ON M7A 2G6 ● Fax 416-326-5135
Page 2 of 4
Part 5: Application for Interim Assistance
Describe your household. How many people, including yourself, are you applying on behalf of?
Adults
Children
Check the box beside those sentences that best describe your situation.
I am looking for work.
I am in an employment assistance program.
I am attending school.
Full-time
Part-time
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.
Other
Are you receiving any money at all?
Yes
No
If you live with your spouse, is he/she receiving any money?
Yes
No
If you or your spouse are receiving money, provide details of your household income below. Include the amount
you receive, when you last received it and how often you receive this income.
Date Last Received
Weekly, Monthly or
Type of Income
Amount
Other (specify)
(dd/mm/yyyy)
Example: Income A
$100.00
01/06/2011
Monthly
Earnings from a job
Vacation pay
Ontario Works (OW)
Ontario Disability Support Program (ODSP)
Workplace Safety & Insurance Benefits (WSIB)
Employment Insurance
Canada Pension Plan
Disability insurance (other than CPP, WSIB)
Support payments
Trust fund income
Ontario Student Assistance Plan (OSAP)
Rental/boarder income
Borrowed money
Foreign pension
Self-employment earnings
Other 1
Other 2
Will you be receiving any money next month that you have not already listed?
Yes
No
What type?
Amount:
Social Benefits Tribunal ● 15 Grosvenor Street, Ground Floor, Toronto, ON M7A 2G6 ● Fax 416-326-5135
Page 3 of 4
Provide the details below of the value of the assets you or any member of your household have.
Bank accounts (personal and business)
Stocks, bonds, GICs
RSPs
Land and property other than your home
Other
How much money do you pay each month for:
Rent
Mortgage
Property taxes
Room and board
Heat
Electricity
Water
Food
Other
Are you behind in any of your payments or unable to pay these expenses?
Yes
No
What expenses have you been late paying or unable to pay?
Have you received an eviction notice or notice your electricity or other service will be shut off?
Yes
No
Provide details:
Below, provide any additional information that you feel the tribunal should know regarding your financial
circumstances.
Name:
Signature:
Date:
Collecting Personal Information: The Social Benefits Tribunal (SBT) collects the personal information requested
on this form under the Ontario Works Act, 1997 or the Ontario Disability Support Program Act, 1997. It will be
used for the purpose of conducting the appeal and will be shared with the parties. If you have any questions,
contact the SBT at 1-800-753-3895.
Social Benefits Tribunal ● 15 Grosvenor Street, Ground Floor, Toronto, ON M7A 2G6 ● Fax 416-326-5135
Page 4 of 4
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