Form 3111E (2018/12), Ontario Works / Ontario Disability Support Program (ODSP) Application for Special Diet Allowance Completed Form Examples and Samples
View a filled-out example of Form 3111E (2018/12), the Application for Special Diet Allowance for Ontario Works (OW) and the Ontario Disability Support Program (ODSP). Our sample helps you understand how to complete the form correctly.
Form 3111E Example – ODSP Special Diet Allowance Application
How this form was filled:
This is a sample of a completed Form 3111E for an individual on the Ontario Disability Support Program (ODSP) with multiple health conditions. The applicant has Diabetes, Celiac Disease, and Lactose Intolerance, which are indicated in Part B by their physician. The form includes all required applicant details, healthcare professional information, signatures, and dates.
Information used to fill out the document:
- Applicant Name: Sarah Jenkins
- Date of Birth: 1985-06-15
- Member ID: 98765432-1
- Address: 456 Elm Street, Toronto, ON, M5G 2C2
- Phone Number: 416-555-0199
- Applicant Signature Date: 2026-02-10
- Healthcare Professional: Dr. Emily Carter, MD
- Professional License/Registration #: 12345
- Facility Name: Maple Leaf Medical Clinic
- Facility Address: 789 Oak Avenue, Toronto, ON, M4P 2L7
- Medical Conditions: Diabetes, Celiac Disease, Lactose Intolerance (Congenital)
- Professional Signature Date: 2026-02-10
What this filled form sample shows:
- Correctly filled Part A with the applicant's personal information for ODSP.
- Part B fully completed by a qualified healthcare professional (Medical Doctor).
- Multiple eligible medical conditions selected from the approved list.
- Properly signed and dated by both the applicant and the healthcare professional.
- Demonstrates how to apply for allowances for more than one condition on a single form.
Form specifications and details:
| Form Name: | Form 3111E (2018/12), Application for Special Diet Allowance |
| Jurisdiction: | Ontario, Canada |
| Program: | Ontario Works / Ontario Disability Support Program (ODSP) |
| Use Case: | ODSP recipient with multiple medical conditions requiring dietary support. |
Created: February 13, 2026 01:57 AM
