docIncome Reporting Statement
download 
Plainte Transcription
Income Reporting Statement
Income Reporting Statement CLIENT’S NAME MEMBER I.D. OFFICE CASE ORG MONTH DBD OVERRIDE INCOME CHANGE YES REPORT ALL GROSS INCOME RECEIVED BY YOU AND YOUR DEPENDANTS FOR THE FOLLOWING PERIOD. DAY MONTH YEAR TO DAY MONTH YEAR MAIL THIS FORM TO THE ADDRESS BELOW AS SOON AS POSSIBLE AFTER AND DAY MAIL INCOME REPORTING STATEMENT TO: MONTH YEAR INITIALS NO INCOME REPORTING STATEMENT I request the continuation of the assistance provided to me under the Ontario Works Act. I declare that to the best of my knowledge and belief: x I am eligible for such assistance; x I have reported all of the income of myself, my spouse and any other dependant persons regardless of age living with me; x Any changes in my address, phone number, living arrangements, persons living with me or assets are reported on this form; x All information stated is true and correct and no requested information has been withheld or omitted. If there have been changes in your circumstances relating to family members, living arrangements, assets or expenses, please note these below. If you no longer require assistance, please indicate why, and return this form to your Caseworker. SIGNATURE DATE (SEE REVERSE SIDE) V-10-040 08/07 Income Reporting Statement CLIENT’S NAME MEMBER I.D. OFFICE CASE ORG MONTH DBD OVERRIDE INCOME CHANGE YES REPORT ALL GROSS INCOME RECEIVED BY YOU AND YOUR DEPENDANTS FOR THE FOLLOWING PERIOD. DAY MONTH YEAR TO DAY MONTH YEAR MAIL THIS FORM TO THE ADDRESS BELOW AS SOON AS POSSIBLE AFTER AND DAY MAIL INCOME REPORTING STATEMENT TO: MONTH YEAR INITIALS NO INCOME REPORTING STATEMENT I request the continuation of the assistance provided to me under the Ontario Works Act. I declare that to the best of my knowledge and belief: x I am eligible for such assistance; x I have reported all of the income of myself, my spouse and any other dependant persons regardless of age living with me; x Any changes in my address, phone number, living arrangements, persons living with me or assets are reported on this form; x All information stated is true and correct and no requested information has been withheld or omitted. If there have been changes in your circumstances relating to family members, living arrangements, assets or expenses, please note these below. If you no longer require assistance, please indicate why, and return this form to your Caseworker. SIGNATURE DATE (SEE REVERSE SIDE) V-10-040 08/07 Income Reporting Statement CLIENT’S NAME MEMBER I.D. OFFICE CASE ORG MONTH DBD OVERRIDE INCOME CHANGE YES REPORT ALL GROSS INCOME RECEIVED BY YOU AND YOUR DEPENDANTS FOR THE FOLLOWING PERIOD. DAY MONTH YEAR TO DAY MONTH YEAR MAIL THIS FORM TO THE ADDRESS BELOW AS SOON AS POSSIBLE AFTER AND MAIL INCOME REPORTING STATEMENT TO: If there have been changes in your circumstances relating to family members, living arrangements, assets or expenses, please note these below. If you no longer require assistance, please indicate why, and return this form to your Caseworker. V-10-040 08/07 DAY MONTH YEAR INITIALS NO INCOME REPORTING STATEMENT I request the continuation of the assistance provided to me under the Ontario Works Act. I declare that to the best of my knowledge and belief: x I am eligible for such assistance; x I have reported all of the income of myself, my spouse and any other dependant persons regardless of age living with me; x Any changes in my address, phone number, living arrangements, persons living with me or assets are reported on this form; x All information stated is true and correct and no requested information has been withheld or omitted. SIGNATURE DATE (SEE REVERSE SIDE) STATEMENT OF INCOME / DÉCLARATION DE REVENU NOTE: IF YOU HAVE NO INCOME TO REPORT, INDICATE “NIL” IN THE BOXES BELOW. REMARQUE: SI VOUS N’AVEZ AUCUN REVENU À DÉCLARER, INSCRIVEZ “NÉANT” DANS LES CASES CI-DESSOUS. GROSS AMOUNT / MONTANT BRUT DESCRIPTION EARNINGS GAIN PARTICIPANT PARTICIPANT(E) SPOUSE CONJOINT(E) GROSS AMOUNT / MONTANT BRUT DEPENDANT PERS. À CH. DESCRIPTION DEPENDANT PERS. À CH. NO. OF MALES Nbre D’HOMMES NO. OF FEMALES Nbre DE FEMMES TOTAL AMOUNT MONTANT TOTAL CPP/QPP - SURVIVOR RPC/RRQ - SURVIVANT TIPS AND GRATUITIES POURBOIRES ET GRATIFICATIONS GROSS FARM INCOME RENTAL INCOME REVENU DE LOCATION CPP/QPP - DISABILITY RPC/RRQ - INVALIDITÉ PRIVATE PENSIONS RÉGIME PRIVÉS DE PENSION WAR VETERANS ALLOWANCE ALLOC. D’ANCIEN COMBAT. OAS / GIS SV / SRG GROSS FARM INCOME REVENU DE LA FERME BRUT GAINS RRAG TRAINING ALLOWANCE ALLOC. DE FORMATION PRIVATE INSURANCE ASSURANCE PRIVÉE GROSS / BRUT NET/NETTE LOANS, GIFTS, OTHER (SPECIFY) PRÊTS, CADEAUX, AUTRE (PRÉCISER) SUPPORT PAYMENTS PENSION ALIMENTAIRE FOREIGN PENSIONS PENS. D’UN PAYS ÉTRANGER INCOME/REVENU EMPLOYMENT INSURANCE ASSURANCE-EMPLOI ROOMERS LOCATAIRES WSIB PERM./TEMP. CSPAAT PERM./TEMP. BOARDERS PENSIONNAIRES IN ORDER TO AVOID ANY INTERRUPTION IN THE PAYMENT OF YOUR ASSISTANCE, COMPLETE THIS FORM AND RETURN BY THE DATE SHOWN ON THE REVERSE. STATEMENT OF INCOME / DÉCLARATION DE REVENU AFIN D’ÉVITER TOUTE INTERRUPTION DU PAIEMENT DE VOS PRESTATIONS, VOUS DEVEZ REMPLIR CETTE CARTE ET L’ENVOYER À LA DATE INDIQUÉE AU VERSO. NOTE: IF YOU HAVE NO INCOME TO REPORT, INDICATE “NIL” IN THE BOXES BELOW. REMARQUE: SI VOUS N’AVEZ AUCUN REVENU À DÉCLARER, INSCRIVEZ “NÉANT” DANS LES CASES CI-DESSOUS. GROSS AMOUNT / MONTANT BRUT DESCRIPTION PARTICIPANT PARTICIPANT(E) SPOUSE CONJOINT(E) GROSS AMOUNT / MONTANT BRUT DEPENDANT PERS. À CH. DESCRIPTION PARTICIPANT PARTICIPANT(E) SPOUSE CONJOINT(E) DEPENDANT PERS. À CH. NO. OF MALES Nbre D’HOMMES NO. OF FEMALES Nbre DE FEMMES TOTAL AMOUNT MONTANT TOTAL CPP/QPP - RETIREMENT RPC/RRQ - RETRAITE GROSS / BRUT NET CPP/QPP - SURVIVOR RPC/RRQ - SURVIVANT TIPS AND GRATUITIES POURBOIRES ET GRATIFICATIONS GROSS FARM INCOME RENTAL INCOME REVENU DE LOCATION CPP/QPP - DISABILITY RPC/RRQ - INVALIDITÉ PRIVATE PENSIONS RÉGIME PRIVÉS DE PENSION WAR VETERANS ALLOWANCE ALLOC. D’ANCIEN COMBAT. OAS / GIS SV / SRG GROSS FARM INCOME REVENU DE LA FERME BRUT GAINS RRAG TRAINING ALLOWANCE ALLOC. DE FORMATION PRIVATE INSURANCE ASSURANCE PRIVÉE GROSS / BRUT NET/NETTE LOANS, GIFTS, OTHER (SPECIFY) PRÊTS, CADEAUX, AUTRE (PRÉCISER) SUPPORT PAYMENTS PENSION ALIMENTAIRE FOREIGN PENSIONS PENS. D’UN PAYS ÉTRANGER INCOME/REVENU EMPLOYMENT INSURANCE ASSURANCE-EMPLOI ROOMERS LOCATAIRES WSIB PERM./TEMP. CSPAAT PERM./TEMP. BOARDERS PENSIONNAIRES IN ORDER TO AVOID ANY INTERRUPTION IN THE PAYMENT OF YOUR ASSISTANCE, COMPLETE THIS FORM AND RETURN BY THE DATE SHOWN ON THE REVERSE. STATEMENT OF INCOME / DÉCLARATION DE REVENU AFIN D’ÉVITER TOUTE INTERRUPTION DU PAIEMENT DE VOS PRESTATIONS, VOUS DEVEZ REMPLIR CETTE CARTE ET L’ENVOYER À LA DATE INDIQUÉE AU VERSO. NOTE: IF YOU HAVE NO INCOME TO REPORT, INDICATE “NIL” IN THE BOXES BELOW. REMARQUE: SI VOUS N’AVEZ AUCUN REVENU À DÉCLARER, INSCRIVEZ “NÉANT” DANS LES CASES CI-DESSOUS. GROSS AMOUNT / MONTANT BRUT DESCRIPTION EARNINGS GAIN SPOUSE CONJOINT(E) CPP/QPP - RETIREMENT RPC/RRQ - RETRAITE GROSS / BRUT NET EARNINGS GAIN PARTICIPANT PARTICIPANT(E) PARTICIPANT PARTICIPANT(E) SPOUSE CONJOINT(E) GROSS / BRUT NET TIPS AND GRATUITIES POURBOIRES ET GRATIFICATIONS GROSS FARM INCOME RENTAL INCOME REVENU DE LOCATION GROSS AMOUNT / MONTANT BRUT DEPENDANT PERS. À CH. DESCRIPTION NO. OF MALES Nbre D’HOMMES NO. OF FEMALES Nbre DE FEMMES TOTAL AMOUNT MONTANT TOTAL CPP/QPP - DISABILITY RPC/RRQ - INVALIDITÉ OAS / GIS SV / SRG GROSS FARM INCOME REVENU DE LA FERME BRUT GAINS RRAG TRAINING ALLOWANCE ALLOC. DE FORMATION GROSS / BRUT NET/NETTE LOANS, GIFTS, OTHER (SPECIFY) PRÊTS, CADEAUX, AUTRE (PRÉCISER) FOREIGN PENSIONS PENS. D’UN PAYS ÉTRANGER INCOME/REVENU EMPLOYMENT INSURANCE ASSURANCE-EMPLOI ROOMERS LOCATAIRES WSIB PERM./TEMP. CSPAAT PERM./TEMP. BOARDERS PENSIONNAIRES IN ORDER TO AVOID ANY INTERRUPTION IN THE PAYMENT OF YOUR ASSISTANCE, COMPLETE THIS FORM AND RETURN BY THE DATE SHOWN ON THE REVERSE. DEPENDANT PERS. À CH. CPP/QPP - SURVIVOR RPC/RRQ - SURVIVANT WAR VETERANS ALLOWANCE ALLOC. D’ANCIEN COMBAT. SUPPORT PAYMENTS PENSION ALIMENTAIRE SPOUSE CONJOINT(E) CPP/QPP - RETIREMENT RPC/RRQ - RETRAITE PRIVATE PENSIONS RÉGIME PRIVÉS DE PENSION PRIVATE INSURANCE ASSURANCE PRIVÉE PARTICIPANT PARTICIPANT(E) AFIN D’ÉVITER TOUTE INTERRUPTION DU PAIEMENT DE VOS PRESTATIONS, VOUS DEVEZ REMPLIR CETTE CARTE ET L’ENVOYER À LA DATE INDIQUÉE AU VERSO.
