Section 2- Income & Assets Information Declaration of Income: Please indicate or for each type of income received by each household member: “yes” “no” Answer or “yes” “no” Name(s) of household Attach the following for each type of TYPE OF INCOME member in receipt of documentation income: income Minimum of eight (8) weeks of Employment Yes____ No___ paystubs Income and Expense Statement Self-Employment Yes____ No___ Notice of Assessment after 12 months of self-employment Statement of Assistance and Ontario Works (OW) Yes____ Drug card Ontario Disability Statement of Assistance and Yes____ No___ Support Program (ODSP) Drug card Support Payments Court Order or Notarized/Sworn Yes____ (received or paid) Separation Agreement Employment Insurance Cheque stub or Source Yes____ No___ (EI) Document Cheque stub or Source Workplace Safety Yes____ Insurance (WSIB) Document Ontario Student Assistance Program Yes____ No___ Loan Document(s) (OSAP) Canada Pension Plan Cheque stub or Source Yes____ No___ (CPP) Document Cheque stub or Source Old Age Security (OAS) Yes____ No___ Document Guaranteed Income Cheque stub or Source Yes____ No___ Supplement Document Cheque stub or Source Other Pension Income Yes____ Document Other Income Yes____ Source Document See page 10 for examples Information slips for Current information slips and/or income tax purposes (T4, Yes____ No___ Notice of Assessment T5, etc.)
Section 2- Income & Assets Information Declaration of Income: Please indicate “yes” or “no” for each type of income received by each household member: TYPE OF INCOME Answer “yes” or “no” for each type of income Name(s) of household member in receipt of income: Attach the following documentation Employment Yes____ No___ Minimum of eight (8) weeks of paystubs Self-Employment Yes____ No___ Income and Expense Statement Notice of Assessment after 12 months of self-employment Ontario Works (OW) Yes____ Statement of Assistance and Drug card Ontario Disability Support Program (ODSP) Yes____ No___ Statement of Assistance and Drug card Support Payments (received or paid) Yes____ Court Order or Notarized/Sworn Separation Agreement Employment Insurance (EI) Yes____ No___ Cheque stub or Source Document Workplace Safety Insurance (WSIB) Yes____ Cheque stub or Source Document Ontario Student Assistance Program (OSAP) Yes____ No___ Loan Document(s) Canada Pension Plan (CPP) Yes____ No___ Cheque stub or Source Document Old Age Security (OAS) Yes____ No___ Cheque stub or Source Document Guaranteed Income Supplement Yes____ No___ Cheque stub or Source Document Other Pension Income Yes____ Cheque stub or Source Document Other Income See page 10 for examples Yes____ Source Document Information slips for income tax purposes (T4, T5, etc.) Yes____ No___ Current information slips and/or Notice of Assessment
2016-08-15_HDN2015-215_%20Attachment%20Income%20Assets%20Review%20Form.docx