Ontario Land Tribunal
655 Bay Street, Suite 1500, Toronto, ON M5G 1E5
Tel: 416-212-6349 | 1-866-448-2248
Web Site: olt.gov.on.ca

Low-Income Fee Waiver Request Form

Instructions:

This form can be used to request a waiver of OLT’s appeal fee.
Prepare this form and submit with your Appeal Form at the time of filing your appeal.
Note: You must fall under the eligibility criteria as set out in the OLT's Low-Income Fee Waiver Policy.
If your request is denied, you will be required to pay the balance owing.

Date Stamp - Received by OLT

Appeal Information
Municipal File Number:	Appeal Type (Official Plan Amendment, Zoning By-law, Development Charges, etc.)	Date of Municipal Decision:

Address and/or Legal Description of Property Subject to the Appeal:

Municipality:	Upper Tier (Region, County, District):	Date Appeal Filed:

Requester Information
Last Name:		First Name:

Company Name or Association Name (Association must be incorporated – include copy of letter of incorporation):

Email Address:
Daytime Telephone Number:			Alternative Telephone Number:
	Ext.

Mailing Address:
Unit Number:	Street Number:	Street Name:	P.O. Box

City/Town:	Province:	Country:	Postal Code:

Reasons to Waive Fee

I am seeking a waiver of the appeal fee on the basis that I am filing the appeal as a private citizen based on the following criteria:
My primary source of household income is from one of the following income support programs or a combination of these programs:

My monthly household income is less than the specified amount in the table below

(Note: The amount is based on the size of your household including dependents and your spouse, if any).

Criteria		Maximum amount
Gross monthly household income Gross monthly household income is the total amount of money that all of the members of your household earn in a month, before taxes or deductions	1 person in your household	$2,600
	2 people in your household	$3,900
	3 people in your household	$4,500
	4 people in your household	$5,400
	5 people in your household	$6,300

Confidentiality Order

I request that a confidentiality order be made with respect to any intimate financial or personal information disclosed as part of this Low-Income Fee Waiver Request.

Affirmation
I affirm the above information is accurate to the best of my knowledge.
_________________________________ Signature	_________________________________ Date
Name of Person Signing:

Personal information or documentation requested on this form is collected under the authority of the Ontario Land Tribunal Act and the legislation under which the proceeding is commenced. All information collected is included in the Ontario Land Tribunal (OLT) case file and the public record in this proceeding. In accordance with the Freedom of Information and Protection of Privacy Act and section 9 of the Statutory Powers Procedure Act, all information collected is available to the public subject to limited exceptions.

We are committed to providing services as set out in the Accessibility for Ontarians with Disabilities Act, 2005. If you have any accessibility needs, please contact our Accessibility Coordinator at OLT.Coordinator@ontario.ca or toll free at 1-866-448-2248 as soon as possible.

OFFICE USE ONLY

Request Received by:

Date Received (dd/mm/yyyy):

Fee Received: $

Approved By:

Request Approved: Yes No

Comments: