Form SC ISP-1151 "Application for Disability Benefits Canada Pension Plan" - Canada

Form SC ISP-1151 or the "Application For Disability Benefits Canada Pension Plan" is a form issued by the Service Canada.

The form was last revised in November 27, 2017 and is available for digital filing. Download an up-to-date fillable Form SC ISP-1151 in PDF-format down below or look it up on the Service Canada Forms website.

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Download Form SC ISP-1151 "Application for Disability Benefits Canada Pension Plan" - Canada

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PROTECTED B (when completed)
Please read the guide before
completing the application
Application for Disability Benefits
Canada Pension Plan
Date Stamp
FOR OFFICE USE ONLY
Application taken by
Year
Month
Day
Information about you
Social Insurance Number
1.
Language
Mr.
Mrs.
Miss
Ms.
Preference
First name and initial
Last name
English
French
Date of birth
FOR OFFICE USE ONLY
Surviving spouse or
Male
Single
Separated
common-law partner
YYYY-MM-DD
Female
Married
Common-Law
Divorced
2. Home address (No., Street, Apt., RR)
City
Province or territory
Country
Postal code
Telephone number
(if other than Canada)
Mailing address if different from home address (No., Street, Apt., PO Box, RR)
City
Province or territory
Country
Postal code
(if other than Canada)
In which year did you
3. If you now live outside of Canada, in which Canadian city and province or territory did you
leave Canada?
last reside?
City:
Province or territory:
4. Payment Information
Direct deposit in Canada:
Complete the boxes below with your banking information.
Branch number (5 digits)
Institution number (3 digits)
Account number (maximum of 12 digits)
Name(s) on the account
Telephone number of your financial institution
Sharing your direct deposit information with the Canada Revenue Agency
For Employment and Social Development Canada (ESDC) and the Canada Revenue Agency (CRA) to share your
personal and direct deposit information, your consent is required.
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada
SC ISP-1151 (2017-11-27) E
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Disponible en français
PROTECTED B (when completed)
Please read the guide before
completing the application
Application for Disability Benefits
Canada Pension Plan
Date Stamp
FOR OFFICE USE ONLY
Application taken by
Year
Month
Day
Information about you
Social Insurance Number
1.
Language
Mr.
Mrs.
Miss
Ms.
Preference
First name and initial
Last name
English
French
Date of birth
FOR OFFICE USE ONLY
Surviving spouse or
Male
Single
Separated
common-law partner
YYYY-MM-DD
Female
Married
Common-Law
Divorced
2. Home address (No., Street, Apt., RR)
City
Province or territory
Country
Postal code
Telephone number
(if other than Canada)
Mailing address if different from home address (No., Street, Apt., PO Box, RR)
City
Province or territory
Country
Postal code
(if other than Canada)
In which year did you
3. If you now live outside of Canada, in which Canadian city and province or territory did you
leave Canada?
last reside?
City:
Province or territory:
4. Payment Information
Direct deposit in Canada:
Complete the boxes below with your banking information.
Branch number (5 digits)
Institution number (3 digits)
Account number (maximum of 12 digits)
Name(s) on the account
Telephone number of your financial institution
Sharing your direct deposit information with the Canada Revenue Agency
For Employment and Social Development Canada (ESDC) and the Canada Revenue Agency (CRA) to share your
personal and direct deposit information, your consent is required.
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada
SC ISP-1151 (2017-11-27) E
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Disponible en français
Social Insurance Number
PROTECTED B (when completed)
4. Payment Information (cont'd)
By selecting "I agree", you agree with these two statements:
- I consent to ESDC sharing with the CRA my direct deposit information entered on this form for any
payments I may receive from the CRA.
- I consent to ESDC sharing with the CRA my Social Insurance Number, last name, and date of birth so that
the CRA can identify me correctly.
If you select "I do not agree", your information will not be shared.
I agree
I do not agree
Direct deposit outside Canada:
For direct deposit outside Canada, please contact us at 1-800-277-9914 from the United States and at 613-957-1954
from all other countries (collect calls accepted). The form and a list of countries where direct deposit service is
available can be found at www.directdeposit.gc.ca.
5. State your last name at birth (if different from Question 1).
State the last name shown on your Social Insurance Number Card (if different from
FOR OFFICE USE ONLY
Question 1).
6. Have you ever lived or worked in another country?
Yes
No
If yes, list below all of the places you have lived or worked outside of Canada and your social security identification
number(s).
Has a benefit
Residence
Employment
Social Security
been requested
Name of
or received from
Number in that
From
To
From
To
that country?
Country
Country
Year
Month
Year
Month
Year
Month
Year
Month
Yes
No
(Note: If you need more space, use a separate sheet of paper.)
If yes, indicate under
7. Have you ever applied for, or received:
Applied
Received
which Social Insurance
Yes
No
Yes
No
Number.
Canada Pension Plan
Quebec Pension Plan
Old Age Security
8. Provide your spouse's or common-law partner's full name and Social
Insurance Number, if available.
Information about your children
Provide information since the time you became disabled until the present.
9. Do you have any children born after December 31, 1958?
If yes, complete the provided "Canada Pension Plan Child Rearing Provision" form
Yes
No
(SC ISP-1640) and return it with this application.
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Social Insurance Number
PROTECTED B (when completed)
Children under age 18
10. Do you have children under the age of 18 in your custody and control?
Yes
No
If yes, provide the following information for each child.
First Child's First name and initial
Last name
Social Insurance Number
Date of birth
FOR OFFICE USE ONLY
Natural Child
Legally Adopted
Male
YYYY-MM-DD
Female
Other (explain circumstances)
Second Child's First name and initial
Last name
Social Insurance Number
Date of birth
FOR OFFICE USE ONLY
Natural Child
Legally Adopted
Male
YYYY-MM-DD
Female
Other (explain circumstances)
If there is insufficient space to list all of your children, use a separate sheet,
notate your Social Insurance Number, sign it and attach it to this application.
Yes
If yes, provide the following information:
11. Do you have children under the age of 18, in the
custody and control of someone else?
No
First Child's First name and initial
Last name
FOR OFFICE USE ONLY
Custodian's full name
Address (No., Street, Apt., or RR)
City
Province or territory
Country
Postal code
(if other than Canada)
Second Child's First name and initial
Last name
FOR OFFICE USE ONLY
Custodian's full name
Address (No., Street, Apt., or RR)
City
Province or territory
Country
Postal code
(if other than Canada)
Children over the age of 18
12. Do you have children between the ages of 18 and 25 attending school, college or university now or within the
past 11 months?
Yes
No
If yes, provide the following information:
First Child's First name and initial
Last name
FOR OFFICE USE ONLY
Address (No., Street, Apt., RR)
City
Province or territory
Country
Postal code
Date of birth
(if other than Canada)
YYYY-MM-DD
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Social Insurance Number
PROTECTED B (when completed)
Children over the age of 18 (cont'd)
FOR OFFICE USE ONLY
Second Child's First name and initial
Last name
Address (No., Street, Apt., RR)
City
Province or territory
Country
Postal code
Date of birth
(if other than Canada)
YYYY-MM-DD
If there is insufficient space to list all of your children, use a separate sheet,
notate your Social Insurance Number, sign it and attach it to this application.
13. On behalf of any of the children listed in this application, has an application previously been made, or have benefits
been received from:
Applied
Received
Canada Pension Plan
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Yes
No
Unknown
Quebec Pension Plan
Social Insurance Number
Social Insurance Number
If yes, indicate under which Social
Insurance Number(s).
Declaration and signature
Part 1
Your personal information is collected under the authority of the Canada Pension Plan (CPP) and will be used to
determine your benefit eligibility and entitlement. The Social Insurance Number (SIN) is collected under the authority of
section 52 of the CPP Regulations, and in accordance with the Treasury Board Secretariat Directive on the SIN, which
lists the CPP as an authorized user of the SIN. The SIN will be used as a file identifier and to ensure your exact
identification so that contributory earnings can be correctly applied to your record to allow benefits and entitlements to
be accurately calculated.
Submitting this application is voluntary. However, if you refuse to provide your personal information, the Department of
Employment and Social Development Canada (ESDC) will be unable to process your application. Your personal
information may be shared within ESDC, with any federal institution, provincial authority or public body created under
provincial law with which the Minister of ESDC may have entered into an agreement and/or with non-governmental third
parties for the purpose of administering the CPP, other acts of Parliament and federal or provincial law as well as for
policy analysis, research and/or evaluation purposes however, these additional uses and/or disclosures of your
personal information will never result in an administrative decision being made about you. The information may be
shared with the government of other countries in accordance with agreements for the reciprocal administration or
operation of the foreign pension program and of the CPP and Old Age Security Act.
Your personal information is administered in accordance with the CPP, the Privacy Act, the Department of Employment
Social Development Act and other applicable laws. You have the right to the protection of, access to, and correction of
your personal information, which is described in Personal Information Bank Canada Pension Plan Program (ESDC PPU
140 and 146). You can ask to see your file by contacting a Service Canada office. Instructions for requesting personal
information are provided in the government publication entitled Info Source, which is available at the following web site
address: www.canada.ca/infosource-ESDC. Info Source may also be accessed on-line at any Service Canada
Centre.
You have the right to file a complaint with the Privacy Commissioner of Canada regarding the institution's handling of
your personal information at: www.priv.gc.ca/en/report-a-concern.
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Social Insurance Number
PROTECTED B (when completed)
Part 2 - To be completed by the applicant
I hereby apply for a disability and, if applicable, a child benefit under the Canada Pension Plan and declare that to the
best of my knowledge and belief, all of the information herein is true and complete.
I agree to notify the Canada Pension Plan of any changes that may affect my eligibility for benefits. This
includes: an improvement in my medical condition; a return to work (full, part-time, volunteer, or trial period);
attendance at school or university; trade or technical training; or any rehabilitation.
Note: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and
interest, if any, under the Canada Pension Plan, or may be charged with an offence. Any benefits you received or
obtained to which there was no entitlement would have to be repaid.
Signature of applicant
Date
(YYYY-MM-DD)
If you change your address, you must notify your nearest Service Canada Office.
Part 3 - To be completed by a witness if the applicant signs with a mark "X"
I have read the contents of this application to the applicant, who appeared to fully understand them and who made
his/her mark in my presence.
Name of witness (print)
Signature of witness
Date
(YYYY-MM-DD)
Address (No., Street, Apt., or RR)
City
Province or territory
Country
Postal code
Telephone number
(if other than Canada)
Part 4 - To be completed only by a representative of the applicant
I hereby apply for a disability and, if applicable, a child benefit under the Canada Pension Plan on behalf of the applicant
and declare that to the best of my knowledge and belief, all of the information herein is true and complete.
I agree to notify the Canada Pension Plan of any changes that may affect the applicant's eligibility for benefits.
This includes: an improvement in the medical condition; a return to work (full, part-time, volunteer, or trial
period); attendance at school or university; trade or technical training; or any rehabilitation.
I also agree to notify the Canada Pension Plan if and when I cease acting as the representative of the applicant
and/or of any changes in the applicant's condition whereby the applicant is able to act on his/her own behalf.
Note: A false or misleading statement may result in an administrative monetary penalty and interest, if any, under the
Canada Pension Plan, or in the prosecution of an offence. Any benefits received or obtained to which there was no
entitlement would have to be repaid.
Signature of representative
Date
Name of representative (print)
Relationship to the applicant
(YYYY-MM-DD)
Address (No., Street, Apt., or RR)
City
Province or territory
Country
Postal code
Telephone number
(if other than Canada)
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