Homemakers and Nurses Services Act
I, an applicant for services under the Homemakers and Nurses Services
I, (complete only where applicable) spouse of the above applicant, consent that: 1. The Welfare Administrator or his or her authorized representative inspect and have access to any account or safety deposit box held by me alone or jointly in any bank, trust company or other financial institution or to any assets held by me or on my behalf by any person, or any records relating to any of them. 2. The Welfare Administrator or his or her authorized representative secure information in respect of any life or accident insurance policy of which I am the beneficiary*.
(*name of insured person, including late spouse, complete only where applicable)
Dated at this day of 20
witness
_________________________________________________
(signature of applicant)
address
(signature of spouse where applicable )
This information is collected in order to determine whether a person who is eligible for homemaking and nurses services is required to pay the fees prescribed for the services. The authority for the collection of this information is section 10 under the Homemakers and Nurses Services Act, R.S.O. 1990, c. H. 10, and Regulation 634, R.R.O. 1990. If you have questions about the collection of this information, please contact the office at the address indicated below.
Homemakers and Nurses Services Program 5700 Yonge Street 5th Floor Toronto, ON M2M 4K5 (416) 327-7039
Homemakers and Nurses Services Act - Form 2 - Consent to Inspect Assets - July 1,2007
2861-69E (07/08)
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