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- Form H31-7797 "Long Term Care Optional Designation for Determining Resident Charges" - Saskatchewan, Canada
Form H31-7797 "Long Term Care Optional Designation for Determining Resident Charges" - Saskatchewan, Canada
Download Form H31-7797 "Long Term Care Optional Designation for Determining Resident Charges" - Saskatchewan, Canada
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1Drug Plan & Extended Benefits
3475 Albert Street
Regina SK S4S 6X6
Phone 306-787-5023
or Toll-Free 1-800-667-4884
Fax 306-787-8679
LONG TERM CARE
OPTIONAL DESIGNATION FOR DETERMINING RESIDENT CHARGE
I,
(name)
residing in
(facility)
hereby wish to be designated as indicated below for purposes of calculating the income-tested
resident charge. I understand that either designation does not automatically designate me in
this way with other social safety net programs in the federal government (e.g. Guaranteed
Income Supplement) and provincial government (e.g. Saskatchewan Assistance Plan and
other Ministry of Health Programs).
Please check the designation applicable to your situation (check only one box). With this
designation only the resident's income is considered in determining the resident charge.
My spouse and I live in separate dwellings for reasons beyond our control.
However, our marital status has not changed.*
I am separated from my spouse pursuant to a separation agreement or a
judicial separation.** Effective Date
Signed this
day of
, 20
.
Resident's Signature or Spouse's/Supporter's Signature
Name of individual signing above (Please Print)
* Commonly called "involuntary separation"
** Sometimes called "legal separation"
H31-7797
2000/10
Drug Plan & Extended Benefits
3475 Albert Street
Regina SK S4S 6X6
Phone 306-787-5023
or Toll-Free 1-800-667-4884
Fax 306-787-8679
LONG TERM CARE
OPTIONAL DESIGNATION FOR DETERMINING RESIDENT CHARGE
I,
(name)
residing in
(facility)
hereby wish to be designated as indicated below for purposes of calculating the income-tested
resident charge. I understand that either designation does not automatically designate me in
this way with other social safety net programs in the federal government (e.g. Guaranteed
Income Supplement) and provincial government (e.g. Saskatchewan Assistance Plan and
other Ministry of Health Programs).
Please check the designation applicable to your situation (check only one box). With this
designation only the resident's income is considered in determining the resident charge.
My spouse and I live in separate dwellings for reasons beyond our control.
However, our marital status has not changed.*
I am separated from my spouse pursuant to a separation agreement or a
judicial separation.** Effective Date
Signed this
day of
, 20
.
Resident's Signature or Spouse's/Supporter's Signature
Name of individual signing above (Please Print)
* Commonly called "involuntary separation"
** Sometimes called "legal separation"
H31-7797
2000/10
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![](https://www.pinterest.com/pin/create/button/?url=https://www.templateroller.com/template/1866727/long-term-care-optional-designation-for-determining-resident-charges-saskatchewan-canada.html&media=https://data.templateroller.com/pdf_docs_html/1866/18667/1866727/long-term-care-optional-designation-for-determining-resident-charges-saskatchewan-canada_big.png&description=Form H31-7797 "Long Term Care Optional Designation for Determining Resident Charges" - Saskatchewan, Canada Download Pdf){kind=small}
Most popular documents
-
"Zappos Kid Shoe Size Chart"
-
"Vsepr Theory (Molecular Shapes) Chart"
-
DD Form 2813
-
DA Form 2062 "Hand Receipt/Annex Number"
-
"NATO Phonetic Alphabet Chart"
-
"Deed of Sale of Motor Vehicle Form" - Philippines
-
AF Form 910 "Enlisted Performance Report (AB Thru TSGT)"
-
DD Form 1750 "Packing List"
-
DD Form 214
-
DA Form 3595 "Record Fire Scorecard"
Popular Articles
- USCIS Form I-551, Permanent Resident Card USCIS Form I-551, Permanent Resident Card
- Washington State Patrol Inspection Request Form Washington State Patrol Inspection Request Form
- Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration Form MV-4ST, Vehicle Sales and Use Tax Return/Application for Registration
- USCIS Form I-797C, Notice of Action USCIS Form I-797C, Notice of Action
- Form REG 124, Application for Assigned Vehicle Identification Number Plate Form REG 124, Application for Assigned Vehicle Identification Number Plate
- Form VSD 190, Application for Vehicle Transaction(s) Form VSD 190, Application for Vehicle Transaction(s)
- Form DOS-1246, Security Guard Renewal Application Form DOS-1246, Security Guard Renewal Application
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