Side A "Institutional Supportive Care - Income-Tested Resident Charge Cra Consent" - Saskatchewan, Canada

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Please return to:
Drug Plan & Extended Benefits Branch
Income Assessment - Operations Unit
Drug Plan and Extended Benefits Branch
3475 Albert Street
Regina, Saskatchewan
S4S 6X6
Phone: 1-800-667-4884 or 306-787-5023
SIDE A
Fax: 306-787-8679
Website:
www.saskatchewan.ca
Institutional Supportive Care - Income-Tested Resident Charge
CRA Consent
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, complete Side B and provide required income documentation.
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 hereby consent to the release, by the Canada Revenue Agency to an official of the Saskatchewan Ministry of Health, of
information from my income tax returns, and, if applicable, other required taxpayer information about me. The information will
be relevant to, and used solely for the purpose of determining and verifying my/our eligibility and the general administration
and enforcement of: the Income Tested Resident Charge pursuant to The Housing and Special-care Homes Act and
regulations made thereunder, and will not be disclosed to any other person or organization without my approval.
This authorization is valid for the most relevant of the two taxation years prior to the year of signature. It is also valid for each
subsequent consecutive taxation year during which my family unit seeks assessment under the Income-Tested Resident
Charge requested by me or on my behalf. I understand that, if I wish to withdraw this consent, I may do so at any time by
writing to Saskatchewan Ministry of Health, Drug Plan and Extended Benefits Branch.
DATE
DATE
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
Income Assessment - Operations Unit
Drug Plan and Extended Benefits Branch
3475 Albert Street
Regina, Saskatchewan
S4S 6X6
Phone: 1-800-667-4884 or 306-787-5023
SIDE A
Fax: 306-787-8679
Website:
www.saskatchewan.ca
Institutional Supportive Care - Income-Tested Resident Charge
CRA Consent
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, complete Side B and provide required income documentation.
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 hereby consent to the release, by the Canada Revenue Agency to an official of the Saskatchewan Ministry of Health, of
information from my income tax returns, and, if applicable, other required taxpayer information about me. The information will
be relevant to, and used solely for the purpose of determining and verifying my/our eligibility and the general administration
and enforcement of: the Income Tested Resident Charge pursuant to The Housing and Special-care Homes Act and
regulations made thereunder, and will not be disclosed to any other person or organization without my approval.
This authorization is valid for the most relevant of the two taxation years prior to the year of signature. It is also valid for each
subsequent consecutive taxation year during which my family unit seeks assessment under the Income-Tested Resident
Charge requested by me or on my behalf. I understand that, if I wish to withdraw this consent, I may do so at any time by
writing to Saskatchewan Ministry of Health, Drug Plan and Extended Benefits Branch.
DATE
DATE
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