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Consent

The document contains a consent and declaration form for an online income support application in Alberta. It includes sections for the applicant to provide personal information, agree to reporting requirements, understand that information will be shared and verified, and consent to the release of tax information to determine eligibility for benefits. The applicant signs the form, providing their name and date, to declare that the information is true and complete.

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tcrothers99
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192 views

Consent

The document contains a consent and declaration form for an online income support application in Alberta. It includes sections for the applicant to provide personal information, agree to reporting requirements, understand that information will be shared and verified, and consent to the release of tax information to determine eligibility for benefits. The applicant signs the form, providing their name and date, to declare that the information is true and complete.

Uploaded by

tcrothers99
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Consent and Declaration

For online Income Support applications

Please print and sign each section, and take a clear photo or scan of each page to upload with your
online Income Support application.

Privacy Notice
The personal information you provide is being collected to determine your eligibility for different
social-based supports and benefits offered by the Government of Alberta under Alberta Supports. If
you choose to apply, the personal information you provide will then be used and disclosed in the
application process, for ongoing eligibility verification, and for delivery of those programs, benefits
or services offered by the Government of Alberta under Alberta Supports, if eligibility is confirmed.

The personal information provided to Alberta Supports is collected, used and disclosed under the
authority of sections 33-40 of the Freedom of Information and Protection of Privacy Act and various
statutes establishing the programs included in Alberta Supports.

If you have questions about the collection of your personal information you can review the
authorizing legislation , or speak to an Alberta Supports Coordinator at the Alberta Supports Contact
Centre at 1-877-644-9992 or 780-644-9992 (Edmonton).

Declaration
1. The information on this application describes the financial and household situation for:

Me or the person for whom I am the Financial Administrator.

My spouse/partner.

My dependents.

2. When I am receiving Income Support benefits, I will report as soon as possible to my worker:

all money that I or anyone in my household receive from any source.


any change in my household situation.
any change in things my spouse/partner or I own.

3. I understand that:

Alberta Community and Social Services (CSS) has the right to apply for child/adult support
for me and/or my dependent children and that the Government of Alberta may retain any of
the support owing to the government.
I must notify and/or receive consent from Child Support Services, CSS when taking my own
support action.

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When required I must help the Government of Alberta to pursue support for me and my
dependent children.

4. I understand CSS has the right to recover benefits I receive to which I am not entitled. This
includes those issued due to administrative error.

5. I understand I have the right to appeal a decision within 30 days of being told of the decision.

6. I understand that CSS and/or CSS contracted services may get information about my financial,
work, educational, medical and/or household situation to:

determine my eligibility for Income Support, or


conduct a review or investigation relating to eligibility or continuing eligibility for these
program benefits.
I ask any person, agency, institution or other source to give the required information to CSS and/or
CSS contracted services.

7. I understand that relevant personal information may be shared with other Government of Alberta
programs and services, including contracted services, and with community partners.

8. I understand CSS may conduct reviews or investigations relating to financial eligibility for this
program. I acknowledge that I must provide information or documents as required by CSS to verify
any statement made on this application or information given to my worker.

9. I understand that I must comply with program expectations to continue to be eligible for benefits.

10. If I am a Financial Administrator or other legal representative, I understand what this Declaration
means as it applies to the applicant.

11. I understand that I must sign the Canada Revenue Agency consent below to be eligible for
benefits.

12. I understand that giving false or incomplete information or not advising of changes in my
situation may result in any or all of the following: termination or suspension of benefits, repayment
of benefits received, and/or laying of a charge under the Income and Employment Supports Act or
the Criminal Code of Canada.

I understand that regardless of who in my family is the designated reporter for the Automated
Reporting for Clients system, it is my responsibility to ensure any changes in my situation have
been reported to the department.

Check Schedules included with this application:

A. Child support services.

C. Declaration of 18 or 19 year old dependent(s).

I declare that the information on this application and required schedules is true and complete.

Trevor Crothers 23-10-2023 ____________________________________


Applicant name Date dd-mm-yyyy Signature

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___-___-_____ ____________________________________
Interpreter or Financial Admin name Date dd-mm-yyyy Signature

___-___-_____ ____________________________________
Worker name Date dd-mm-yyyy Signature

Canada Revenue Agency Authorization


I consent to the release, by Canada Revenue Agency to an official of Alberta Community and Social
Services, of information from my income tax returns and other taxpayer information about me
whether supplied by me or a third party. The information will be relevant to, and will be used solely
for the purpose of determining, verifying and/or auditing my/our eligibility and for the general
administration and enforcement of programs under the Income and Employment Supports Act. This
consent is valid for the taxation year prior to the year of signature, the current taxation year and for
each subsequent taxation year for which assistance is requested.

Trevor Crothers 23-10-2023 ____________________________________


Applicant name Date dd-mm-yyyy Signature

Generated by Income Support | October 23, 2023 | Community and Social Services Page 3 of 3

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