"Mandatory or Change Report Form - Saskatchewan Supplement Programs" - Saskatchewan, Canada

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Download "Mandatory or Change Report Form - Saskatchewan Supplement Programs" - Saskatchewan, Canada

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Saskatchewan Supplement Programs
Saskatchewan Supplement Programs
PO Box 2405
Regina, SK S4P 2Z9
Mandatory or Change Report Form
Email: sesreport@gov.sk.ca
Complete all information on both sides of this form. The applicant must sign and date the form in order for
it to be accepted as your Mandatory Report. This report must be received in our office between the 1st and
18th of the month. Please send in your report as early as possible to avoid delay to your payment. If you have
ongoing income you may complete your income reports by email at sesreport@gov.sk.ca.
Please Note:
Changes to your address or family unit must be updated with eHealth by calling
1-800-667-7551 or visiting their website at https://www.ehealthsask.ca/residents/health-cards. You will need
to call the Client Service Centre (CSC) 3 to 4 business days after this is completed. Please call the CSC if you
have any questions or concerns regarding your SRHS or SES payments.
Account Number u
Reason for Report:
q
q
Mandatory Report
Reporting Changes (Only report income, Address
(Quarterly Report)
or Family changes)
Client
Primary Client
Spouse (if applicable)
Information
Name
Address
Password
n/a
Phone Number
Email Address
Name of Employer
Income Assistance
Are you receiving?
q
SAP
q
SAID
q
TEA
q
SIS
Amount
saskatchewan.ca
| June 2019
saskatchewan.ca |
Page 1
Saskatchewan Supplement Programs
Saskatchewan Supplement Programs
PO Box 2405
Regina, SK S4P 2Z9
Mandatory or Change Report Form
Email: sesreport@gov.sk.ca
Complete all information on both sides of this form. The applicant must sign and date the form in order for
it to be accepted as your Mandatory Report. This report must be received in our office between the 1st and
18th of the month. Please send in your report as early as possible to avoid delay to your payment. If you have
ongoing income you may complete your income reports by email at sesreport@gov.sk.ca.
Please Note:
Changes to your address or family unit must be updated with eHealth by calling
1-800-667-7551 or visiting their website at https://www.ehealthsask.ca/residents/health-cards. You will need
to call the Client Service Centre (CSC) 3 to 4 business days after this is completed. Please call the CSC if you
have any questions or concerns regarding your SRHS or SES payments.
Account Number u
Reason for Report:
q
q
Mandatory Report
Reporting Changes (Only report income, Address
(Quarterly Report)
or Family changes)
Client
Primary Client
Spouse (if applicable)
Information
Name
Address
Password
n/a
Phone Number
Email Address
Name of Employer
Income Assistance
Are you receiving?
q
SAP
q
SAID
q
TEA
q
SIS
Amount
saskatchewan.ca
| June 2019
saskatchewan.ca |
Page 1
Sources of Income
Primary Client
Spouse
Monthly Gross Income
Monthly Gross Income
Income Source
Employment
$
$
Child/spousal support
$
$
Old Age Security (OAS) and Guaranteed Income
$
$
Supplement (GIS)
Personal retirement pension funds
$
$
Other government benefits (CPP, SGI wage
$
$
replacement)
Other income (state type of income)
$
$
Farming/Self-employment
$
$
Residents of Your Home
Who resides in the home? Please provide names, Personal Health Number, and date of birth
for all individuals.
Relation to Primary
Date of Birth
Name
Health Number
Client
(MMM/DD/YYYY)
How much is your monthly rent? $ _______________
Do you pay for heat?
q
YES
q
NO
saskatchewan.ca |
Page 2
Health and Safety
YES
NO
Do all of the outside doors to your residence close properly and have locks that work?
q
q
If you have a balcony over two feet off the ground, does it have a railing?
q
q
Are the floorboards in the steps and staircases in the home in good shape with no rotten
q
q
or missing boards?
Does your roof or any of your windows always leak when it rains?
q
q
Do you have any exposed electrical wires?
q
q
Do both your bathroom and kitchen have hot and cold running water?
q
q
Does your bathroom have a working bathtub, shower, or sink?
q
q
Does your home have a working toilet?
q
q
Does your home have a working source of heat?
q
q
Do you have working smoke detectors?
q
q
Do you have a constant problem with rodents in your home?
q
q
Does your residence have a foundation that is caving in?
q
q
Does every bedroom have a window that opens?
q
q
If you have previously reported that you have disability supports in place in or around the
q
q
home. Are these supports still in place?
If you have previously provided reference person. Has this contact information changed?
q
q
If yes, please use the Comments section below to provide the new contact information.
Comments or Additional Information
Declaration
I, _____________________________________ of ______________________________ , Saskatchewan, do solemnly
declare that all of the information is true and complete. I make this solemn declaration sincerely believing it to be
true, and knowing that it is of the same force and effect as if made under oath. I understand that I may be liable to
criminal prosecution for withholding information or providing false or misleading information.
Client’s Signature _______________________________________
Date: _____________________________
saskatchewan.ca |
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