Government of Ontario: Ministry of Health and Long-Term Care

Application for Services Form 1

Homemakers and Nurses Services Act

To the Welfare Administrator of the
of

I apply for the services of homemaker nurse

under the Homemakers and Nurses Services Act and in support of my application, I make the following statements:

1. Surname
Given name(s)
Address
(no., street or R.R., City, Town, Post Office or Township, County etc).

Marital status single married widowed separated deserted divorced

Date (yyyy/mm/dd) Place

3. Personal and family data - Applicant and dependent members of family living together

Given name(s) (surname if different from applicant) Applicant
Sex
Date of birth (yyyy/mm/dd)
Age
Birthplace
Relationship to applicant
Health (good/fair/poor)

Given name(s) (surname if different from applicant) Spouse
Sex
Date of birth (yyyy/mm/dd)
Age
Birthplace
Relationship to applicant
Health (good/fair/poor)

Given name(s) (surname if different from applicant)
Sex
Date of birth (yyyy/mm/dd)
Age
Birthplace
Relationship to applicant
Health (good/fair/poor)

4i. Members of family not living with applicant

Relationship
Full name
Address
Contribution

4ii. Where the application for services is being made by reason of the absence of the mother or other person having charge of a child in the household owing to hospitalization or other institutional care, state name and address of hospital or institution.

State reason for the admission of the mother or the other person to hospital or institution.

State probable length of stay in hospital or institution.

5. State in detail reasons that the services of a homemaker or nurse are required:

6. Check if in receipt of:
employment assistance or basic financial assistance under the Ontario Works Act, 1997
payment under the Old Age Security Act (Canada)
income support under the Ontario Disability Support Program Act, 1997

7i. Assets
Type of asset
yes no
In whose name
Name of bank, organization or company
Amount on deposit or value of asset
Yearly income of dividend

Type of asset
yes no
In whose name
Name of bank, organization or company
Amount on deposit or value of asset
Yearly income of dividend

Type of asset
yes no
In whose name
Name of bank, organization or company
Amount on deposit or value of asset
Yearly income of dividend

Type of asset
yes no
In whose name
Name of bank, organization or company
Amount on deposit or value of asset
Yearly income of dividend

Type of asset
yes no
In whose name
Name of bank, organization or company
Amount on deposit or value of asset
Yearly income of dividend

Type of asset
yes no
In whose name
Name of bank, organization or company
Amount on deposit or value of asset
Yearly income of dividend

Type of asset
yes no
In whose name
Name of bank, organization or company
Amount on deposit or value of asset
Yearly income of dividend

7ii.

Real property (details of real estate owned by members of household) Description
Owner
Assessed value
Encumbrance
Annual taxes

Total arrears of Taxes
Interest

Description
Owner
Assessed value
Encumbrance
Annual taxes

Total arrears of Taxes
Interest

Description
Owner
Assessed value
Encumbrance
Annual taxes

Total arrears of Taxes
Interest

Description
Owner
Assessed value
Encumbrance
Annual taxes

Total arrears of Taxes
Interest

Debts Owing to whom
Details
Amount

Owing to whom
Details
Amount

Owing to whom
Details
Amount

9. Narrative: (Health and Welfare circumstances: particular family or individual problems and needs: future plans; contact with other agencies etc.)

Date(yyyy//mm/dd)

Signature of Applicant

10. To be completed by Welfare Administrator

Type of services provided homemaker nurse

Services rendered by: private organization - name and address

Municipal or band staff - name of staff member

other (specify)

Rates: Homemaker
Per visit
Per day (8 hours)
Per hour

Nurse
Per visit
Per day (8 hours)
Per hour

Amount paid by applicant
Per visit
Per day (8 hours)
Per hour

Amount paid by Municipality
Per visit
Per day (8 hours)
Per hour

Date(yyyy//mm/dd)

Signature of Welfare Administrator

Approved by (signature of provincial authority)

2859-69E (07/2007)

Disponible en Français

7530-5237