Side B "Institutional Supportive Care - Income-Tested Resident Charge Annual Application" - Saskatchewan, Canada

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Please return to:
Drug Plan & Extended Benefits Branch
Drug Plan and Extended Benefits Branch
Income Assessment
Operations Unit
SIDE B
3475 Albert Street
Regina, Saskatchewan
S4S 6X6
Phone: 1-800-667-4884 or 306-787-5023
Fax: 306-787-8679
Website:
www.saskatchewan.ca
Institutional Supportive Care - Income-Tested Resident Charge
Annual Application
Completing Side B means that you must apply for the program each year.
Provide a copy of your Notice of Assessment OR pages 1 to 4 of your Income Tax Return showing Line 150 (for both
Resident and Spouse).
If you do not file income tax, please include a written explanation and provide all documentation from all sources of income.
(some examples: cheque stubs, T4 slips)
Incomplete applications will result in delays in processing. Please ensure you have provided all information.
RESIDENT INFORMATION (Please Print)
SPOUSE INFORMATION (Please Print)
Resident’s Surname
First
Spouse’s Surname
First
Health Services Number
Date of Birth (YY/MM/DD)
Health Services Number
Date of Birth (YY/MM/DD)
Social Insurance Number
Social Insurance Number
CONTACT INFORMATION (Please Print)
Surname
First
Current Mailing Address
Home Phone Number
Work Phone Number
City/Town/Village
Postal Code
(
)
(
)
DECLARATION AND CONSENT
Is the Power of Attorney (POA) signing on behalf of the resident?
YES
NO
If YES, then copies of the POA documents MUST be attached. NOTE: If a Trustee, Guardian or POA is signing for the Applicant, a copy of the
legal document must be attached to this consent form. Due to the variety of POA documents, some may not be considered acceptable for
CRA, such as POA specific to or limited to a bank or financial institution.
“I declare that all the information I have provided is complete and correct in all respects and fully discloses my
total income from all sources. I further consent to the use of this information by the Saskatchewan Ministry of
Health for the purpose of determining my entitlement for other Health Care benefits or programs but will not be
disclosed to any other person or organization without my approval.”
Signature of Resident, or if applicable, Guardian/Trustee/ Power of
Signature of Spouse, or if applicable, Guardian/Trustee/ Power of Attorney. A
Attorney. A witness is necessary if resident signs with an “X” or a mark.
witness is necessary if spouse signs with an “X” or a mark.
PRINT NAME OF Guardian/Trustee/ Power of Attorney/Witness.
PRINT NAME OF Guardian/Trustee/ Power of Attorney/Witness.
08/2010
Please return to:
Drug Plan & Extended Benefits Branch
Drug Plan and Extended Benefits Branch
Income Assessment
Operations Unit
SIDE B
3475 Albert Street
Regina, Saskatchewan
S4S 6X6
Phone: 1-800-667-4884 or 306-787-5023
Fax: 306-787-8679
Website:
www.saskatchewan.ca
Institutional Supportive Care - Income-Tested Resident Charge
Annual Application
Completing Side B means that you must apply for the program each year.
Provide a copy of your Notice of Assessment OR pages 1 to 4 of your Income Tax Return showing Line 150 (for both
Resident and Spouse).
If you do not file income tax, please include a written explanation and provide all documentation from all sources of income.
(some examples: cheque stubs, T4 slips)
Incomplete applications will result in delays in processing. Please ensure you have provided all information.
RESIDENT INFORMATION (Please Print)
SPOUSE INFORMATION (Please Print)
Resident’s Surname
First
Spouse’s Surname
First
Health Services Number
Date of Birth (YY/MM/DD)
Health Services Number
Date of Birth (YY/MM/DD)
Social Insurance Number
Social Insurance Number
CONTACT INFORMATION (Please Print)
Surname
First
Current Mailing Address
Home Phone Number
Work Phone Number
City/Town/Village
Postal Code
(
)
(
)
DECLARATION AND CONSENT
Is the Power of Attorney (POA) signing on behalf of the resident?
YES
NO
If YES, then copies of the POA documents MUST be attached. NOTE: If a Trustee, Guardian or POA is signing for the Applicant, a copy of the
legal document must be attached to this consent form. Due to the variety of POA documents, some may not be considered acceptable for
CRA, such as POA specific to or limited to a bank or financial institution.
“I declare that all the information I have provided is complete and correct in all respects and fully discloses my
total income from all sources. I further consent to the use of this information by the Saskatchewan Ministry of
Health for the purpose of determining my entitlement for other Health Care benefits or programs but will not be
disclosed to any other person or organization without my approval.”
Signature of Resident, or if applicable, Guardian/Trustee/ Power of
Signature of Spouse, or if applicable, Guardian/Trustee/ Power of Attorney. A
Attorney. A witness is necessary if resident signs with an “X” or a mark.
witness is necessary if spouse signs with an “X” or a mark.
PRINT NAME OF Guardian/Trustee/ Power of Attorney/Witness.
PRINT NAME OF Guardian/Trustee/ Power of Attorney/Witness.
08/2010