DS****A Rev. ****-**

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AISH Application - General Information

Submit the AISH Application and supporting documents by: 1. Complete Part A Applicant Information, and use the Application Checklist on the next page to gather copies of the documents you must provide.

2. Take Part B Medical Report to your doctor to complete. You will have to pay a fee to the doctor to complete the report. If you need help paying the fee, contact the Alberta Supports Contact Centre for options. The doctor can send the Medical Report, with supporting documents directly to AISH and give you a copy, or the doctor can send the report and documents to you, to add to Part A of your application. 3.

mailing them to PO Box 17000 Station Main, Edmonton, AB, T5J 4B3; or

taking them to your nearest AISH office / Alberta Supports Centre; or

submitting them online at https://aish-apply.alberta.ca.

faxing them to 587-***-**** (Edmonton Area) or 1-877-***-****; or Introduction

The Assured Income for the Severely Handicapped (AISH) program provides financial and health benefits to eligible Albertans with severe and permanent disabilities. Depending on your situation, these benefits may include:

A living allowance Personal benefits Health benefits Child benefits Applying for AISH

Use Your Guide to Completing the AISH Application to help you fill in the AISH application and know which documents you need to include. Get help if you need it, by:

having someone help you complete the application,

calling the Alberta Supports Contact Centre at 1-877-***-****, or

contacting or visiting an AISH office listed at the back of the guide or go to albertasupports.ca to find an Alberta Supports Centre in your area.

The AISH Application has 2 parts:

Part A: Applicant Information (for you to complete) Part B: Medical Report (for your doctor to complete) Follow these steps:

After Part A and Part B are submitted to AISH:

You will be contacted by phone or mail:

if more information is needed; and/or

once a decision is made about your application.

If you need more space for any sections, you may attach additional pages. You may also attach any other relevant letters, documentation, or materials to support your application. 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. To see the list of the programs, including the legislation authorizing each program, please click humanservices.alberta.ca/authorizing-legislation.html or request a printed copy. If you have questions about the collection of your personal information, please contact the Alberta Supports Contact Centre toll-free at 1-877-***-****.

DS2444A Rev. 2019-07

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Application Checklist Instructions

Use this checklist to make sure you include copies of all the documents that are required for your AISH application. Refer to Your Guide to Completing the AISH Application for more information and examples of the documents you may need. Documents for Section 1 - Information About You

Copy of identification document(s) that shows your full legal name, date of birth, recent picture, and signature.

Proof that you live in Alberta showing your street or rural land address, not a post office box. Copy of your Record of Landing if you immigrated to Canada under sponsorship within the last 10 years.

Documents for Section 2 - Spouse/Partner Information Copy of identification document(s) for your spouse or partner that shows their full legal name, birth date, recent picture, and signature.

Documents for Section 3 - Dependent Children Information Copy of identification document(s) for any dependent children you or your partner have that shows full legal name and date of birth.

Documents for Section 4 - Trustee/Power of Attorney Information Copy of a letter or document that shows the legal authority of a person or organization to act as your Trustee or under a Power of Attorney.

Documents for Section 8 - Income Information

Copy of document(s) for all income you or your spouse or partner receive. Documents for Section 9 - Asset Information

Copy of document(s) for all assets you or your spouse or partner have. To avoid delays with your application, please make sure you:

answer all questions that apply to your situation,

provide all documents, and

sign the Declaration and Consents.

Please do not submit original documents as they will not be returned to you. DS2444A Rev. 2019-07 Part A - Page 1 of 9

File Section 4

AISH Application - Part A

DS2444A Applicant Information

Your Situation

If any of the following apply to your situation, you may not need to complete the entire application. Skip Section 6 Employment History and Section 7 Education and Training History, and provide your medical documentation instead of completing Part B of the application, if: I am receiving end-of-life palliative care, and/or have been diagnosed with a terminal illness. I have been assessed as needing long term care or designated supportive living. Skip Section 8 Income Information and Section 9 Asset Information, if: I am receiving Income Support benefits from Alberta Works. Submit Part A of the application and do not complete Part B, unless contacted by an AISH worker, if: I have applied for, or am applying for, the Persons with Developmental Disabilities (PDD) program. Contact an AISH office to find out how to apply, if: I left the AISH program less than 2 years ago and my medical condition has not changed. Complete the entire application, if:

None of the above apply.

Section 1 - Information About You

Provide a copy of identification document(s) that shows your full legal name, date of birth, recent picture, and signature, proof you live in Alberta, and Record of Landing (if applicable). Last Name First Name Middle Name

Last Name on Birth Certificate (if different) Other Preferred First Name (alias) Gender

Male Female

Social Insurance Number (SIN)

Alberta Personal Health Number Home Phone Other Phone (if applicable) Marital Status (check one) (if married or in a partner relationship please fill out Partner Information section) Single Married Partner Separated from Spouse or Partner Divorced Widowed Are you a resident of

Alberta? Yes No

What is your citizenship/immigration status?

Canadian Citizen Permanent Resident Sponsored Immigrant Other, specify:

If Yes, indicate sponsorship start date and end date.

(include copy of Record of Landing) Start Date yyyy-mm-dd End Date yyyy-mm-dd Check the box that describes your living situation Rent Own Live with family Shelter Facility Institution

Group home Other

Apartment Unit # Street or Land Address where you live City/Town Province/Territory Postal Code

Mailing Address (if different from above)

City/Town Province/Territory Postal Code

Date of Birth: Year Month Day

DS2444A Rev. 2019-07 Part A - Page 2 of 9

File Section 4

Section 2 - Spouse/Partner Information

Do you have a spouse/partner? Yes No

Provide a copy of identification document(s) for your spouse/partner that shows their full legal name, date of birth, recent picture, and signature.

Last Name First Name Middle Name

Last Name on Birth Certificate (if different) Other Preferred First Name (alias) Gender

Male Female

Social Insurance Number (SIN)

Is your spouse/partner currently receiving AISH?

Yes No

If No, go to Section 3.

Date of Birth: Year Month Day

Section 3 - Dependent Children Information

Last Name First Name Middle Name

If 18/19 years, is child attending high school?

Yes No

Does this child live with you?

Yes No

Provide a copy of identification document(s) for any dependent child(ren) that includes the child's full legal name and date of birth.

Do you have a dependent child(ren)? Yes No If No, go to Section 4. Date of Birth: Year Month Day

Last Name First Name Middle Name

If 18/19 years, is child attending high school?

Yes No

Does this child live with you?

Yes No

Date of Birth: Year Month Day

Last Name First Name Middle Name

If 18/19 years, is child attending high school?

Yes No

Does this child live with you?

Yes No

Date of Birth: Year Month Day

Section 4 - Trustee/Power of Attorney Information

Trustee/Attorney Last Name Trustee/Attorney First Name Trustee/Attorney Phone Number Mailing Address City/Town Province/Territory Postal Code Do you have a Trustee or someone currently acting under a Power of Attorney? Yes No If No, go to Section 5. Provide a copy of a letter or document for a person or organization that shows their legal authority to act as your trustee or under a Power of Attorney (Attorney).

DS2444A Rev. 2019-07 Part A - Page 3 of 9

File Section 4

Section 5 - Medical Information

Doctors

Who is your current family doctor?

Name Phone

Address City/Town Province/Territory Postal Code

Have you been treated by doctors or specialists other than your family doctor during the past two years? If yes, please provide:

Yes No

Name Type of Doctor/Specialist Phone

Address City/Town Province/Territory Postal Code

Name Type of Doctor/Specialist Phone

Address City/Town Province/Territory Postal Code

Describe your medical condition and the impact it has on you and your ability to work. Add more pages if you need more space. Medical Condition

DS2444A Rev. 2019-07 Part A - Page 4 of 9

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Section 6 - Employment History

Have you ever been employed? Yes No If No, proceed to Section 7. If you need to add more Employment History, add more pages. Employer Name (indicate if self-employed)

Start date yyyy-mm Are you currently working with this employer? Yes No

If No, employment end date yyyy-mm

Full-time Part-time Seasonal/Sporadic Volunteer/Unpaid Other Occupation / role / type of work

Reason for leaving this job (if applicable)

Because of your medical condition Other

Employer Name (indicate if self-employed)

Start date yyyy-mm Are you currently working with this employer? Yes No

If No, employment end date yyyy-mm

Full-time Part-time Seasonal/Sporadic Volunteer/Unpaid Other Occupation / role / type of work

Reason for leaving this job (if applicable)

Because of your medical condition Other

Employer Name (indicate if self-employed)

Start date yyyy-mm Are you currently working with this employer? Yes No

If No, employment end date yyyy-mm

Full-time Part-time Seasonal/Sporadic Volunteer/Unpaid Other Occupation / role / type of work

Reason for leaving this job (if applicable)

Because of your medical condition Other

Employer Name (indicate if self-employed)

Start date yyyy-mm Are you currently working with this employer? Yes No

If No, employment end date yyyy-mm

Full-time Part-time Seasonal/Sporadic Volunteer/Unpaid Other Occupation / role / type of work

Reason for leaving this job (if applicable)

Because of your medical condition Other

DS2444A Rev. 2019-07 Part A - Page 5 of 9

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Section 7 - Education/Training History

What is the highest education level you have completed? No formal education

Grade 1-12 (indicate last grade completed and year) Last grade completed Year yyyy

College/University (state institution, course, level completed, degree obtained and year) Institution

Course Level completed

Degree obtained Year yyyy

Training or upgrading (indicate training completed and year) Training completed Year yyyy

Technical/Trades/Journeyman (indicate institution, course, level completed, certificate or diploma obtained and year) Institution

Course Level completed

Certificate or diploma obtained Year yyyy

Other

Year yyyy

What steps, if any, have you taken to find work or training suitable for your medical condition(s)? Are you currently involved with training or upgrading? Yes No If yes, name of provider Location

Type of program Date started yyyy-mm Expected completion date yyyy-mm Are you planning to take further training or upgrading? Yes No If yes, please specify the type of training or upgrading you are planning to take. What are your goals upon completion? DS2444A Rev. 2019-07 Part A - Page 6 of 9

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Section 8 - Income Information

Indicate Yes if you and/or your spouse/partner receive any of the following income, or No if you do not. If you answer Yes give the average month amount and provide documentation. Some of the income types below may be fully or partially exempt for you and/or spouse or partner. However you must report all income listed to help AISH understand your financial situation and determine eligibility. For more information about how income is treated, please refer to Your Guide to AISH. Refer to Your Guide to Completing the AISH Application for more information and examples of documents you will need. Applicant

If Yes, Average

Monthly Amount

Spouse/Partner

If Yes, Average

Monthly Amount

Employment Income

(provide 3 most recent months of pay stubs) Yes No $ Yes No $ Self-Employment Income Yes No $ Yes No $

Employment Insurance (EI) Income Yes No $ Yes No $ Life Insurance Income Yes No $ Yes No $

Disability/Wage Loss Insurance Income Yes No $ Yes No $ Old Age Security Benefits Yes No $ Yes No $

Canada Pension Plan Benefits Yes No $ Yes No $

Guaranteed Income Supplement Income Yes No $ Yes No $ Pension income from previous employment Yes No $ Yes No $ Spousal Support Income Yes No $ Yes No $

Workers’ Compensation Benefits Yes No $ Yes No $

Rental Income Yes No $ Yes No $

Investment Income Yes No $ Yes No $

Trust Income Yes No $ Yes No $

1. Do you have any other income? Yes No

If Yes, specify the type of income, amount and provide documentation. 2. Have you received a special payment in the past 12 months? Yes No If Yes, specify the type of payment, amount, date it was received, and provide documentation. (See the list of special payments in Section 8 of the Your Guide to Completing the AISH Application.)

DS2444A Rev. 2019-07 Part A - Page 7 of 9

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Bank Account(s)

How many do you have? Yes No $ Yes No $

Section 9 - Asset Information

Indicate Yes if you and/or your spouse/partner have any of the these assets, or No if you do not. If you answer Yes give the current market value and provide documentation. For more information about how assets are treated, please refer to Your Guide to AISH. Refer to Your Guide to Completing the AISH Application for more information and examples of documents you will need. Cash and uncashed Cheques Yes No $ Yes No $

Guaranteed Investment Certificates (GIC), Term

Deposits Yes No $ Yes No $

Registered Retirement Savings Plan (RRSP),

Registered Retirement Income Fund (RRIF) Yes No $ Yes No $ Annuities Yes No $ Yes No $

Locked-In Retirement Account (LIRA)* Yes No $ Yes No $ Registered Disability Savings Plan (RDSP)* Yes No $ Yes No $ Registered Education Savings Plan (RESP) Yes No $ Yes No $ Tax-Free Savings Account (TFSA) Yes No $ Yes No $

Stocks, Bonds Yes No $ Yes No $

Life Insurance (cash surrender value) Yes No $ Yes No $ Trusts* Yes No $ Yes No $

Vehicle(s)**

How many do you have? Yes No $ Yes No $

Vehicle adapted for a disability** Yes No $ Yes No $ Recreational vehicle(s) (e.g. motorhome, boat,

snowmobile, etc.) Yes No $ Yes No $

Other Vehicle Yes No $ Yes No $

Home / principal residence* Yes No $ Yes No $

Recreational property Yes No $ Yes No $

Farm Yes No $ Yes No $

Provide the following documents: most recent property tax assessment, mortgage documents, balance sheet, business asset insurance, list of all farm vehicles, farm insurance, machinery and equipment (include current value, year, make and model). Do you live on a home quarter section?* Yes No $ Yes No $ Do you own land other than the home quarter

section? Yes No $ Yes No $

Business Yes No $

Provide the following documents: most recent property tax assessment, mortgage documents, business income, tax notice of assessment, business income tax return, accounting statement/balance sheet, business asset insurance. Yes No $

Rental property Yes No $ Yes No $

Applicant

If Yes,

Approximate Value

Spouse/Partner

If Yes,

Approximate Value

* These assets are exempt and do not affect your eligibility for AISH benefits. However, you must report them along with other assets listed above to help AISH understand your financial situation and determine eligibility.

** These assets may be exempt depending on your situation. DS2444A Rev. 2019-07 Part A - Page 8 of 9

File Section 4

Section 10 - Declaration

1. I declare that the information I am giving about me, my spouse/partner (if applicable) and my dependent child(ren) (if applicable) is true and complete and I understand that hiding information or giving false or incomplete information on purpose is an offence that could result in criminal charges. 2. If I am a Guardian, Co-decision-maker, Agent, Trustee or Attorney (under a Power of Attorney), I understand what this declaration means as it applies to the applicant.

Applicant Name (print) Date yyyy-mm-dd Signature

Guardian/Co-decision-maker/Agent Name (print) Date yyyy-mm-dd Signature Trustee/Attorney Name (print) Date yyyy-mm-dd Signature Section 11 - Consents

AISH Consent

I give my permission to any person, agency, organization, institution or other source to give the AISH program and/or AISH contracted services any information about my household situation, education and training, employment, and finances AISH asks for to decide if I am eligible for AISH. I understand I may withdraw my consent, in writing, at any time. Applicant Name (print) Date* yyyy-mm-dd Signature

Guardian/Co-decision-maker/Agent Name (print) Date* yyyy-mm-dd Signature Trustee/Attorney Name (print) Date* yyyy-mm-dd Signature

*Date consent is effective.

If you would like to name a person or organization the AISH program can contact or who can contact the AISH program about your application please provide the following information: Name of Person/Organization (print) Phone Number

Canada Revenue Agency Consent

I authorize Canada Revenue Agency to release information required from my tax file to the Alberta Ministry of Community and Social Services. The information will be relevant to and used solely for the purpose of determining and verifying my eligibility, or the eligibility of my co-habiting partner, for benefits under the Assured Income for the Severely Handicapped Act (c. A-45.1, 2006), and the general administration and enforcement of the benefit programs. This authorization is valid for the taxation year prior to the year of signature of this consent, the current taxation year, and each subsequent consecutive taxation year for which assistance is requested. I understand that if I wish to withdraw this consent, I may do so in writing to the Alberta Ministry of Community and Social Services. Applicant Name (print) Date* yyyy-mm-dd Signature

Trustee/Attorney Name (print) Date* yyyy-mm-dd Signature Spouse/Partner Name (print) (if applicable) Date* yyyy-mm-dd Signature DS2444A Rev. 2019-07 Part A - Page 9 of 9

File Section 4

Canada Pension Plan - Disability (CPP-D) Consent

I understand the AISH program requires applicants to use all income, and that CPP-D is a benefit I may be entitled to. If I am eligible for AISH benefits, I agree to have a CPP-D representative decide if I am eligible for CPP-D benefits. If the CPP-D representative decides I am not eligible for CPP-D based on my earnings and contributions, they will share that information with AISH and I will not need to apply for CPP-D. To decide my eligibility for CPP-D, I give my permission to AISH to share the following information with CPP-D: a. AISH Medical Report (Part B, Application Form) filled out by my doctor, and any other reports or documents that will help the programs decide my medical eligibility; and b. my completed AISH Application form.

To decide my eligibility for, and the amount of my AISH benefits, I give my permission to CPP-D to share the following information with AISH:

a. CPP-D will tell AISH whether or not I need to apply for CPP-D; and b. CPP-D's decision about my CPP-D benefit and the amount of the benefit I will receive. I understand I may withdraw my consent, in writing, at any time, and that this consent is in place for three years from the date* I (or my Guardian/Co-decision-maker/Agent/Trustee/Attorney) sign it. 1.

2.

3.

4.

5.

*Date consent is effective.

Section 11 Continued - Consents

Applicant Name (print) Date* yyyy-mm-dd Signature

Guardian/Co-decision-maker/Agent Name (print) Date* yyyy-mm-dd Signature Trustee/Attorney Name (print) Date* yyyy-mm-dd Signature

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