Application for the Reusable Hygiene Product Initiative Middlesex County

Date

Applicant’s name (Ontario Works/ODSP client):

Address:

Phone:

Email (if applicable):

	Menstrual Products
Menstrual cup	Menstrual cup
Washable menstrual pad/tampon/panty liner	Washable menstrual pad/tampon/panty liner
Absorbent menstrual underwear	Absorbent menstrual underwear

	Your Assistance Program:
Ontario Works	Ontario Works
ODSP	ODSP

Your Member ID Number (OW/ODSP):

Note: We ask for this information to a) shape how we offer related benefits in the future, to better suit your needs, and b) to aid the proof-of-purchase step.

This Application is Being Submitting For (Select all that Apply):

Myself

An eligible member of my household (an individual who is of an age and sex that will receive benefit from the product).

The total number of people you are applying for:

Total amount you are applying for ($):

I am a current Ontario Works or ODSP client with the County of Middlesex, and I pledge that the products for which I am submitting an application for reimbursement are for myself and/or a dependent living in my household.

Please note, this benefit will only be available as long as funds are available. It is recommended to estimate the cost of the item(s), submit your application, and receive funding and only then purchase your item. Please buy the item within one (1) month of receiving the funds. Please keep your proof-of-purchase, such as a copy of the original receipt given to you at point-of-sale. This document should contain visible product details, such as product name or barcode number (UPC), and the date and price of the sale. The County may request a copy to confirm the product’s identity.

I agree

After you apply, the County will verify your identity in our system, by matching the personal details you gave here (name, address, etc.), to those listed on your file. After we confirm you are a current client, the benefit will be paid out to you by the normal means (e.g. bank deposit or cheque, whatever you normally receive). Any inconsistencies may cause your application to be denied.