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

Corporate Services Division

Rate Reduction Application in Long-Term Care
Document List Required for Assessment of Resident Eligibility

To be used only by Residents Submitting a Notice of Assessment for the Year When they were 64 Years of Age

As a resident of a LTC home, you are required to pay a co-payment for your accommodation. This requirement is set out in the Long-Term Care Homes Act, 2007 (the Act).
The Rate Reduction Program is intended to provide a reduction in the co-payment amount you are required to pay based on your available income. Only residents residing in basic accommodation may apply for a reduction in the co-payment amount.
Before you can apply for a rate reduction you need to apply for other income support and benefit programs available through the federal, provincial and municipal government.
In order to fairly assess your application for a reduction in the co-payment, otherwise known as a “rate reduction”, it is important that you report all income available to you.
As a resident applying for rate reduction you may be required to have a Notice of Assessment. You will also be required to report all the income sources available to you.
This supporting document list will help you determine whether you have the required documentation to apply for a rate reduction. The documentation required will be used to assess:
- Your eligibility based on whether you have accessed all available income; and
- Your rate reduction based on the income available to you.

Instructions

Please complete this document by checking “Yes” or “No” for the income sources you are receiving and whether you have the supporting documents required.
Please ensure you submit this form and all your documents to staff in your LTC Home when you bring in your completed and signed Rate Reduction Application Form.
Note: This list is for guidance only. Based on your unique circumstances you may be required to provide additional documents. The home processing your application may ask you for additional information and documentation in order to complete a Rate Reduction Application.

Step 1: Check if you are required to have Notice of Assessment and prepare your Notice of Assessment Document

All residents are required to have a Notice of Assessment (NOA). This is the document Canada Revenue Agency sends back to you after you have filed your tax return along with your refund cheque or statement of balance owing.

There is an exception to the requirement for a Notice of Assessment for residents who have been residing in a long-term care home for less than or equal to a year.
This document list requires a Notice of Assessment. If you do not have a Notice of Assessment, fill out the alternate Supporting Document List for Residents Applying for Rate Reduction Without a Notice of Assessment.


Mandatory Document	Check if Support Document Provided
Residents who have Notice of Assessment (NOA) from their most recent tax year are required to provide their NOA to Apply for Rate Reduction	Check if Support Document Provided Yes No

Step 2: Check which benefits I am required to apply for and prepare the required documents

You are required to access available benefits before you can apply for a rate reduction. Based on your age, Column A outlines which benefits you are expected to receive or apply for if you are not currently receiving them.

If you have applied for the benefit listed in Column A, based on your age, and have been denied or found ineligible you will be required to submit a copy of the document listed in Column B. This document will outline the decision regarding your eligibility for the benefit. This document will be required before your rate reduction application can be processed by a LTC home.

Column C and D will guide you through the process of determining whether you are ready to file your rate reduction application by answering some questions.


Column A	Column B	Column C	Column D
Income Source	Document	Are you receiving the benefit, select yes or no.	If you said “no” in the previous column because you have applied for the benefit and were found not eligible for the benefit, then you will be required to provide a copy of the document listed under the Column B. Have you provided the required document, select yes or no.
Residents 65 years and over only
Old Age Security (OAS)	Service Canada Rate Letter	Are you receiving the benefit, select yes or no. Yes No	If you said “no” in the previous column because you have applied for the benefit and were found not eligible for the benefit, then you will be required to provide a copy of the document listed under the Column B. Have you provided the required document, select yes or no. Yes No
Guaranteed Income Supplement (GIS)	Service Canada Rate Letter	Are you receiving the benefit, select yes or no. Yes No	If you said “no” in the previous column because you have applied for the benefit and were found not eligible for the benefit, then you will be required to provide a copy of the document listed under the Column B. Have you provided the required document, select yes or no. Yes No
Canada Pension Plan (CPP) - Retirement or Quebec Pension Plan (QPP)	Service Canada Rate Letter or Regie des rentes Quebec Rate Letter	Are you receiving the benefit, select yes or no. Yes No	If you said “no” in the previous column because you have applied for the benefit and were found not eligible for the benefit, then you will be required to provide a copy of the document listed under the Column B. Have you provided the required document, select yes or no. Yes No
For residents not eligible for OAS, Ontario Disability Support Program will be required for resident with a Notice of Assessment showing a line 236 less than $12,552 (i.e. $1,046 per month)	Notice of Decision Letter from ODSP	Are you receiving the benefit, select yes or no. Yes No	If you said “no” in the previous column because you have applied for the benefit and were found not eligible for the benefit, then you will be required to provide a copy of the document listed under the Column B. Have you provided the required document, select yes or no. Yes No
Residents 64 Years and Under Only
Ontario Disability Support Program for resident with a Notice of Assessment showing a line 236 less than $12,552 (i.e. $1,046 per month)	Notice of Decision Letter from ODSP	Are you receiving the benefit, select yes or no. Yes No	If you said “no” in the previous column because you have applied for the benefit and were found not eligible for the benefit, then you will be required to provide a copy of the document listed under the Column B. Have you provided the required document, select yes or no. Yes No
Resident aged 60 to 64
Canada Pension Plan (CPP) – Retirement or Quebec Pension Plan (QPP)	Service Canada Rate Letter or Regie des rentes Quebec Rate Letter	Are you receiving the benefit, select yes or no. Yes No	If you said “no” in the previous column because you have applied for the benefit and were found not eligible for the benefit, then you will be required to provide a copy of the document listed under the Column B. Have you provided the required document, select yes or no. Yes No

Step 3: Collecting supporting documents for income not included in your Notice of Assessment

The following table corresponds to Part B of the Rate Reduction Application Form. If you are currently receiving income from any of the sources listed below, you will be required to report the income amount and provide the document listed below:


Column A	Column B	Column C	Column D
Income Source	Document	Are you receiving income from this source, select yes or no.	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no.
Please note: Other Benefits includes Benefits of any kind, including benefits that provide partial or full reimbursement of accommodation charges and Any accident benefits payable or court awarded settlements including Income Replacement, Non-Earner and Caregiver Benefits, Medical, Rehabilitation and Attendant Care Benefits
For all residents
Non-Governmental and non-taxable private insurance Income Replacement Benefits Death Benefits - Residents receiving Death Benefits will have the benefit amount excluded from their income. Survivor Benefits Other Benefits Under the Statutory Accident Benefits Schedule Other Benefits (See definition below)	Private Insurance Letter	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Income Sources from Foreign Country	Foreign Country Letter	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Support Payments Due and Owing to the Resident	Court Order/Support Agreement Amount, and “Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No

The following table corresponds to Part B of the Rate Reduction Application Form. Your Notice of Assessment may include certain income sources that are excluded from the income calculation. The amounts to be excluded are determined based on your supporting document. If you have any of the following income sources you will need to provide the documents listed below for them to be excluded:


Column A	Column B	Column C	Column D
Income Exclusion	Document	Are you receiving income from this source, select yes or no.	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no.
For all residents
Universal Child Care Benefit	“Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Registered Disability Savings Plan	“Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
CPP or QPP Death Benefit	T4A (P) Tax Slip	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
For residents that received a rate reduction in the last year
RRSPs Used to Pay for an Assistive Device	Supplier Receipt & “Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
New residents or residents that did not receive a rate reduction in the last year
RRSPs Used to Pay for LTC home accommodation	Invoice Document for Accommodation Paid & “Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Employment Income	“Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Elected Split Pension Income	“Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
RRSP Income	“Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
RRIF and LIF Income	“Option-C Printout”	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No

If you are submitting a Notice of Assessment for the year in which you were 64 years of age then the Notice of Assessment will reflect benefits that you are no longer receiving and will exclude the benefits you have begun receiving since turning 65 years of age. In order for this change to be reflected in your income calculation you will be required to provide the following documents.


Column A	Column B	Column C	Column D
Previous Benefits (Received by resident prior to turning 65 years of age)	Document	Did you receive the following benefit prior to turning 65 and was it included in your Notice of Assessment, select yes or no.	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no.
For residents who where 64 years of age during the year covered by their Notice of Assessment
Ontario Disability Support Program (ODSP) or Ontario Works (OW)	T5007	Did you receive the following benefit prior to turning 65 and was it included in your Notice of Assessment, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Old Age Security (OAS) Spousal Allowance	“Option-C Printout”	Did you receive the following benefit prior to turning 65 and was it included in your Notice of Assessment, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Old Age Security (OAS) Allowance for the Survivor	“Option-C Printout”	Did you receive the following benefit prior to turning 65 and was it included in your Notice of Assessment, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Canada Pension Plan (CPP) -Disability, Quebec Pension Plan (QPP) Disability	T4A (P)	Did you receive the following benefit prior to turning 65 and was it included in your Notice of Assessment, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Canada Pension Plan (CPP) Survivor Benefit, Quebec Pension Plan (QPP) Surviving Spouse’s Pension	T4A (P)	Did you receive the following benefit prior to turning 65 and was it included in your Notice of Assessment, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Canada Pension Plan (CPP) Children’s Benefit, Quebec Pension Plan (QPP) Orphan’s Pension	T4A (P)	Did you receive the following benefit prior to turning 65 and was it included in your Notice of Assessment, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No

The following list corresponds to Part C of the Rate Reduction Application Form. If you have begun receiving a new benefit in the last 18 months, it may not be included in your Notice of Assessment. You will be required to report the income amount for any of the following benefits and provide the document listed below.


Column A	Column B	Column C	Column D
Income Source	Document	Are you receiving income from this source select yes or no.	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no.
The resident’s NOA, “Option-C Printout” and T4A (P) slip are required to be from the resident’s most recent tax year: Rate Reduction application received from July 1 to December 31 must be accompanied by documents from the previous year; Rate Reduction application received from January 1 to June 30 may be accompanied by documents from the two-years prior to only when documents from the previous year are not yet available to the resident.
For all resident
Canada Pension Plan (CPP) Retirement or Quebec Pension Plan (QPP)	Service Canada Rate Letter or Regie des rentes Quebec Rate Letter	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Old Age Security (OAS)	Service Canada Rate Letter	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Guaranteed Income Supplement (GIS)	Service Canada Rate Letter	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No
Guaranteed Annual Income System (GAINS)	Ministry of Revenue Rate Statement Letter	Are you receiving income from this source, select yes or no. Yes No	If you said “Yes” to the previous column you will be required to provide the document listed in Column B. Have you provided the required document, select yes or no. Yes No

Glossary

Income Tax - Notice of Assessment Form
To replace lost copy of Notice of Assessment form, contact the Canada Revenue Agency at 1 800 959-8281.

Option-C Printout
It is the equivalent of the last notice of assessment you would have received in respect of the most recent taxation year and will serve as a basis for your income assessment.

This printout is issued by the Canada Revenue Agency (CRA, formerly CCRA) and you can obtain it free of charge by calling 1 800 959-8281. Your dependent will also have to obtain an “Option-C Printout”.

If you are not able to obtain and produce an “Option-C Printout”, you will need to provide documentation establishing the amount of income you earned over the period of 12 months preceding the date of your application (i.e. bank statements if you have received interest income; statement of interest if you have other sources of income).

T4A (P) – Canada Pension Plan benefits slip
Canada Pension Plan benefits slip is sent to taxpayers who received any of the following from the government:

Retirement Benefits
Survivor Benefits
Child Benefits
Disability Benefits
Death Benefits

Old Age Security (OAS)
OAS is a monthly pension benefit available to eligible Canadians over age 65, even if they have never worked.

Guaranteed Income Supplement (GIS)
GIS provides additional monthly income to eligible individuals already receiving OAS.

Canada Pension Plan – Retirement (CPP-R)
CPP-R is a monthly pension benefit available to individuals who have contributed to the Canada Pension Plan. CPP-R is designed to replace about 25% of an individual’s earnings from employment up to a maximum amount.

Ontario Disability Support Program (ODSP)
ODSP provides income to eligible individuals with disabilities who are in financial need.

Income Replacement Benefits
This benefit compensates for lost income if you are unable to perform the essential tasks of the job you did before the accident.

Death Benefit
Death benefit is a one-time payment to, or on behalf of, the estate of a deceased Canada Pension Plan contributor.

Survivor Benefits
Survivor benefits are paid to a deceased contributor’s estate, surviving spouse or common-law partner and dependent children.

Income Sources from Foreign Country
An annual income sources from foreign countries in Canadian dollars for the annual net calculation using Bank of Canada currency exchange rates.

Financial Income Sources Inquiries Guide

The following guide is meant to provide members of the public direction as to the appropriate governmental and non-governmental offices to direct their federal / provincial benefits, entitlements, supplements, settlement or other financial income sources inquiries.

Resident NOA or C-Print - Line 236
Inquiries should be directed to Revenue Canada Agency at: 1 800 959-8281 or TTY (Teletypewriter) 1 800 665-0354

OAS - Service Canada Letter
Inquiries should be directed to Service Canada at: 1 800 O-Canada (1 800 622-6232) or TDD/TTY (Teletypewriter)
1 800 926-9105 or the Service Canada Web site http://www.servicecanada.gc.ca/.

GIS - Service Canada Letter
Inquiries should be directed to Revenue Canada Agency at: 1 800 277-9914 or TTY (Teletypewriter) 1 800 255-4786
Please note: You can also re-apply for GIS by filing your income tax return. The Seniors section of the Canada Revenue Agency's Web site (i.e. http://www.cra-arc.gc.ca/tx/ndvdls/sgmnts/snrs/menu-eng.html) contains information on filing your tax return.

CPP-R - Service Canada Letter or CPP-R cheque stub inquiries should be directed to Service Canada at:
1 800 O-Canada (1 800 622-6232)TDD/TTY (Teletypewriter) 1 800 926-9105, a Service Canada Centre near you (http://www.servicecanada.gc.ca/cgi-bin/hr-search.cgi) or the Service Canada Web site (http://www.servicecanada.gc.ca/)

ODSP - ODSP Notice of decision letter OR ODSP cheque stub
Inquiries should be directed to the Ministry of Community and Social Services at: 1 888 789-4199

Private Insurance Income Sources
Inquiries should be directed to resident’s private insurance companies. The resident will be required to submit his/her insurance policy, or insurance benefit letter to verify the amounts required to be included in the resident’s annual net income.