Woman completing a Regional Municipality of Durham online form on a computer.

Form Builder

Required fields are marked with asterisks (*)

Specialized Services Eligibility Appeal Form

Please fill out the online form below to appeal your eligibility for specialized services.

Alternatively, if you wish to print this form and submit via mail, fax or email, please click here to open a printable version of this form, and send it one of the following ways:

First Name

Last Name

Date of birth

Address

Apartment or Unit Number

City

Postal Code

Phone Number (preferred)

Phone Number (other)

Email Address