Saskatchewan Income Support

Financial Review Declaration Box 2405 Stn. M

Regina, SK S4P 4L7
Phone: 1-866-221-5200
Email: [email protected]

Your Information
Last Name First Name SIS Client Number
Blondeau Jacie
Date of Birth (yyyy/mmm/dd) Box/Street Number & Name City/Town Postal Code

Name of Spouse/Partner Spouse/Partner’s Date of Birth (yyyy/mmm/dd)

1. Do you have dependents living with you? * Yes * No If yes, complete the following:

Date of Birth Are you receiving Canada Child

Last Name, First Name (yyyy/mmm/dd) Benefit (CCB) for this child?

* Yes * No
* Yes * No
* Yes * No
* Yes * No
a. If you are not receiving Canada Child Benefit (CCB) for any child dependents living with you, have you applied
for each child? *
Yes No *
b. If yes, when did you apply? Indicate date(s): _____________________________________________________

c. If no, why have you not applied? _______________________________________________________________

2. Do you or anyone in your household have money or investments (such as money in the bank, RRSPs,
other investments)? Yes * *
No If yes, complete the following. You must provide statement copies.

What is the Financial

Asset Description Value of Asset In Whose Name is the Asset Institution?

3. Do you or anyone in your household have assets (such as property or vehicles)? * Yes * No
If yes, complete the following:

Asset Description Registered Owner Address or Legal Description *Equity Value

* Equity value is the present value of the asset minus what you owe.

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 4. Have you sold, traded, transferred to given away any assets (such as cash, savings bond, home, land, etc.) since your last
financial review? * Yes * No If yes, complete the following:

Asset description Date of disposal Amount received How money received was spent

5. Have you or your spouse/partner received any income from any source since you applied or last completed a financial
review (such as wages, taxes, child support, student loan, income tax refund, CCB, pension, employment insurance)?
* Yes * No If yes, complete the following:

Source of income Date received Name of person who received it Amount

6. Are you or your spouse/partner expecting income from any source (such as wages, taxes, child support, student loan,
income tax refund, CCB, pension, employment insurance)? *
Yes *
No If yes, complete the following:

Source of income Date received Name of person who received it Amount

7. Do you have a formal arrangement to live, stay or sleep somewhere? * Yes * No

Supporting documentation is required. If not previously provided, please include your tenancy agreement.

8. Do you pay to heat your home with electric heat, propane, oil, wood or coal? * Yes * No
Supporting documentation is required. Please include current receipts.

You are expected to use direct deposit for your benefits. Please complete the Direct Deposit Form if you are not currently
receiving your benefits by direct deposit. If you are unable to establish direct deposit for your benefits, contact the program
at the above number.

Review and sign the Declaration on the following pages.

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Declaration

I state the information a e e is true, correct and complete and that I have not withheld any information which may
a ea a e benefits a e g . I understand I may be subject to criminal prosecution i
information or provide false or misleading information.

My Rights
I/We have the right to:
• a e personal information and personal health information e e a a e The Freedom of
Information and Protection of Privacy Act and The Health Information Protection Act;
• request a copy of the information I provide to the Ministry of Social Services about myself;
• apply for a review of the assessment of eligibility or the calculation of income support;
• be treated with respect in all interactions with Ministry of Social Services staff;
• withdraw consent at any time by contacting the Ministry of Social Services at 1-866-221-5200. This w a a ill
a e effect the date I notify e a not be retroactive;
• contact the Ministry of Social Services Privacy Officer if I/we have questions or concerns related to our privacy rights
(email [email protected] a .

My Responsibilities
I/We agree to:
• report all changes a e e e e a e a e e . This includes address
changes, changes in the number of my family members, any money I or my a e e may get including e-
transfers a a e ae a a g, and any other changes that may affect my eligibility e
a a e e e ;
• make every effort to support myself, including looking for employment or training to the best of my abilit e ;
• follow up on all sources of income, including child support and benefits available through other government programs;
• create, participate and be accountable to an agreed upon a e plan with the Ministry of Social Services; a
• update any changes to my email account with the Ministry of Social Services.
I/We understand:
• The Ministry of Social Services collects and uses my/our personal information and personal health information to provide
e us services and benefits I/we need a a e e a a ag ee e g:
- The Ministry of Social Services will subtract any payments I get that I am not entitled to from future income support
payments;
- e a e e a e e a e e a e ga a a
a e e a e
- I am responsible for repaying any overpayments I get if I fail to report a a ge my or my spouse’s/partner’s
a e;
- I am responsible for repaying an a g overpayment to the Ministry of Social Services e e e a
ge e g e e ;
- The Ministry of Social Services will keep and dispose of the information I provide in my application according to
approved records retention schedules, as required by The Archives and Public Records Management Act;
- The Ministry of Social Services may ask for additional personal information for the purposes of data analytics. I/We
understand I/ e can choose whether to provide this information and that my/our decision will not impact eligibility
for services or benefits; a
- The Ministry of Social Services will communicate with me using the email address linked to my Saskatchewan.ca
account. I understand I am responsible for checking this email regularly.

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 • a e e ga e e e a e a e e a e ae e e
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agg e e e a a ea

Declaration

I/We, _____________________________ and _____________________________ do solemnly declare that all of the information
in this application is true and complete. I/We make this solemn declaration believing it to be true, knowing that it is of the same
force and effect as if made under oath.

I/We understand that I/we may be a e criminal prosecution for withholding information or providing false or misleading
information.
Yes, I Agree. Yes, Spouse Agrees

_________________________________________________ _________________________________________________
Client Signature Spouse/Partner Signature

_________________________________ _________________________________
Date Date

Client Consent

I/We give consent to the Ministry of Social Services to collect, use and disclose my or my family’s Social Insurance Number(s)
Health Services Number(s) a to determine eligibility for income support.

I/We give consent to the Ministry of Social Services to collect, use and disclose information provided voluntarily (such as Driver’s
e e or Non-Driver’s ID number(s), gender etc.).

I/We give consent to the Ministry of Social Services to collect, use and disclose information or documents required to confirm my
or my family’s eligibility and for the purposes of case a e planning. Such planning activities may include developing
money management skills, accessing services from third parties, obtaining and maintaining utility services, career training and
assistance with job applications. I/We understand this information includes money received from any source (including e-
transfers) to verify assets and to verify relationship status. Examples include, but are not restricted to, information or documents
from:

• Employment and Social Development Canada (Employment Insurance Program);

• Workers’ Compensation Board;
• Saskatchewan Government Insurance;
• any bank, credit union or other financial institution;
• a e g e a P e a a eg
• any landlord, past employers and providers of pre-employment services or programs for the time period I am e a e
in receipt of Saskatchewan Income Support a
• e e a e e g e a a ga a
a e ga

I/We give consent to the Ministry of Social Services to share my or my family’s information to third parties and to collect and use
information from those third parties where the information is necessary to verify and confirm eligibility for income a a e, or
to assist in providing case a e planning. I understand my information (name, date of birth and address) will be
shared with SaskPower and SaskEnergy to identify individuals that receive services from the Ministry and either/or SaskPower
and SaskEnergy, for the purpose of case a e planning. e a a a e ae a
a e e ae a e a e e a e a a e ee ge g e
a a e a e e a ga a a e Other examples of third parties include, but are not
restricted to:

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 • a e
• Canada Revenue Agency;
• Ministry of Advanced Education;
• Ministry of Education;
• Ministry of Immigration and Career Training;
• e a a a ee a g a e e
• Workers’ Compensation Board;
• Canada Pension Plan; and
• First Nation Bands.

I/We give consent to the Ministry of Social Services to use and disclose my information (including information provided
voluntarily) for research and evaluation purposes within the inistry. I/We understand this may include information collected
from me or other sources. I/We give consent to the Ministry of Social Services to use my data in research and evaluation projects
that may involve my information held by Social Services being combined with other government ministries and agencies.

ee e a e a e e a ea e a ea e e a
a a a Pe Pa ea e e ea

Canada Revenue Agency requires we provide you with a speci ic consent statement.

I/We authorize the Canada Revenue Agency to release income and expense information and related identifying information
about me or my family from income tax records to the Ministry of Social Services. The inistry will use the information only to
determine and verify my or my family’s eligibility for income support through the Saskatchewan Income Support program, and
for collecting overpayments of income support under that program that I or my family were not entitled to. The inistry will not
share this information to any person or organization without my or my family’s written approval or unless required to be disclosed
by operation of law (for example: subpoenas or other legislative requirements to disclose information). This authorization is valid
for the taxation year of the application date and all following taxation years for which I/We request income support. I/We
understand that I or my family may withdraw this consent by writing to the Ministry of Social Services.

_________________________________________________ _________________________________________________
Client Signature Spouse/Partner Signature

_________________________________ _________________________________
Date Date

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