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

Application for Reimbursement by the Province
Homemakers and Nurses Services Act

Account for the month of
Corporation (municipality), District Board or Approved Band of the

County or District

Part I Cost of Homemakers services purchased by the Municipality District Board or Approved Band from a person or organization under Section 5 of the Act

Total hours

Total cost

Number of hours

@ $ per hour

Number of days

@ $ per day

(x hours/day)

Number of weeks

@ $ per week

hours/week

Travel expenses:

Total hours of service

Less: Total available monthly income of persons served
(Item 26 of Form 4 Determination of Monthly Income 4500-69)

Net cost to municipality, district board or approved band

Part II Cost of services provided by a Homemaker, who is an employee of the Municipality, District Board or Approved Band, under Section 5 of the Act

Full time employees
- time worked (HH:MM) :

Part time employees
- time worked (HH:MM) :

Total Full time + Part time employees
- time worked (HH:MM) :

Salaries:

Staff benefits approved by the Director:

Travel expenses:

Total Cost

Less: Total available monthly income of persons served
(Item 26 of Form 4 Determination of Monthly Income 4500-69)

Net cost to municipality, district board or approved band

Part III Statistics re Part I and Part II

	Purchased service	Service by staff
No. of family cases	Number of family cases, purchased service	Number of family cases, service by staff
No. of person in family
Adult - 60 years of age or more	No. of person in family, Adult - 60 years of age or more, purchased service	No. of person in family, Adult - 60 years of age or more, service by staff
Other adults	No. of person in family, Other adults, purchased service	No. of person in family, Other adults, service by staff
Children (under 16 years of age)	No. of person in family, Children (under 16 years of age), purchased service	No. of person in family, Children (under 16 years of age), service by staff
Single Case
60 years of age or more	Single Cases, 60 years of age or more, purchased service	Single Cases, 60 years of age or more, service by staff
Others	Single Cases, Others, purchased service	Single Cases, Others, service by staff

Part IV Cost of Nurses services purchased by the Municipality District Board or Approved Band from a person or organization under Section 5 of the Act

Number of visits

@ $ per visit

Travel expenses:

Total Cost

Less: Total available monthly income of persons served
(Item 26 of Form 4 Determination of Monthly Income 4500-69)

Net cost to municipality, district board or approved band

Part V Cost of services provided by a Nurse who is an employee of the Municipality, District Board or Approved Band, under Section 5 of the Act.

Full time employees
- time worked (HH:MM) :

Part time employees
- time worked (HH:MM) :

Total Full time + Part time employees
- time worked (HH:MM) :

Salaries:

Staff benefits approved by the Director:

Travel expenses:

Total Cost

Less: Total available monthly income of persons served
(Item 26 of Form 4 Determination of Monthly Income 4500-69)

Net cost to municipality, district board or approved band

Part VI Statistics re Part IV and Part V

	Purchased service	Service by staff
family cases	family cases, purchased service	family cases, service by staff
Adult - 60 years of age or more	Adult - 60 years of age or more, purchased service	Adult - 60 years of age or more, service by staff
Other adults	Other adults, purchased service	Other adults, service by staff
Children (under 16 years of age)	Children (under 16 years of age), purchased service	Children (under 16 years of age), service by staff
Single Case
60 years of age or more	Single Case, 60 years of age or more, purchased service	Single Case, 60 years of age or more, service by staff
Others	Single Case, Others, purchased service	Single Case, Others, service by staff

Note: If more space is required, figures may be listed on a separate sheet and attached, but total should appear on this signed form.

Part VII Certificate

We certify that:

This application for provincial subsidy is correct.
The amounts shown have been disbursed in accordance with the regulations.
This application is in agreement with the records of the municipality, district board or approved band making the application.

Welfare Administrator (first name, last name)

Address Number Street Name
City/Town Province Postal Code

Welfare Administrator’s Signature

Treasurer (first name, last name)

Address Number Street Name
City/Town Province Postal Code

Treasurer’s Signature

Part VIII For Ministry Use Only

Net cost to municipality, district board or approved band
Part I	Total Cost part 1 $
Part II	Total Cost part 1 $
Part IV	Total Cost part 1 $
Part V	Total Cost part 1 $
Total Cost	Total Cost $

Adjustment specify:

MM /YYYY

+ or -

Number of homemaking hours/travel time hours

@ $

Adjusted net cost to the municipality, district board or approved band

Less: Municipality, district board or approved band portion (20% of adjusted net cost)

Ministry share

Plus: Adjustment for rate reform (A above)

Reimbursement by the province

Approved for payment by (first name, last name)

Signature
Date (yyyy/mm/dd)

Version française disponible

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

Application for Reimbursement by the Province Homemakers and Nurses Services Act

Part I Cost of Homemakers services purchased by the Municipality District Board or Approved Band from a person or organization under Section 5 of the Act

Part II Cost of services provided by a Homemaker, who is an employee of the Municipality, District Board or Approved Band, under Section 5 of the Act

Part III Statistics re Part I and Part II

Part IV Cost of Nurses services purchased by the Municipality District Board or Approved Band from a person or organization under Section 5 of the Act

Part V Cost of services provided by a Nurse who is an employee of the Municipality, District Board or Approved Band, under Section 5 of the Act.

Part VI Statistics re Part IV and Part V

Part VII Certificate

Part VIII For Ministry Use Only

Application for Reimbursement by the Province
Homemakers and Nurses Services Act