APPLICATION FOR INCOME ASSISTANCE Part 2 APPLICATION FOR

APPLICATION FOR INCOME ASSISTANCE (Part 2) APPLICATION FOR DISABILITY ASSISTANCE (Part 2) APPLICANT 1 LAST NAME FIRST NAME SIN MARITAL STATUS BIRTHDATE (YYYY MMM DD) APPLICANT 2 LAST NAME FIRST NAME SIN DATE SEPARATED/DIVORCED (IF APPLICABLE) BIRTHDATE (YYYY MMM DD) ADDRESS POSTAL CODE TELEPHONE ( YES, STATE AMOUNT $ IF SEPARATED OR DIVORCED, HAVE YOU APPLIED FOR FINANCIAL SUPPORT FROM YOUR SPOUSE? ) NO, GIVE REASON ALL OTHER PERSONS LIVING IN HOUSEHOLD EXCLUDING APPLICANT(S) RELATIONSHIP APPLICANT 1 APPLICANT 2 DATE MOVED TO CANADA DEP YES NO BIRTHDATE (YYYY MMM DD) YYYY MMM DD DATE MOVED TO B. C. YYYY MMM DD MOVED FROM (PROVINCE/COUNTRY) CANADIAN CITIZEN? YES NO ELIGIBLE UNDER LMDA? EXPLANATION FOR NOT SEEKING EMPLOYMENT YES HAVE YOU FILED AN INCOME TAX RETURN FOR THE PREVIOUS TAX YEAR? Sam ple APPLICANT 1 If you are completing this form after June 30 th, the previous tax year is last year, otherwise it is the year before last year. YES APPLICANT 2 YES NO ALL MONTHLY FAMILY INCOMES NO APPLICANT 2 APPLICANT 1 DEPENDANTS NO YES NO OWNED BY: APPLICANT 2 APPLICANT 1 DEPENDANTS TAKE HOME PAY (NET EARNINGS) $ $ $ CASH ON HAND $ $ $ SUPPORT OR MAINTENANCE $ $ $ 1 ST VEHICLE $ $ $ ROOMER $ $ $ 2 ND VEHICLE $ $ $ RECREATIONAL VEHICLE $ $ PROPERTY (NOT INCLUDING HOME) $ $ LIFE INSURANCE (CASH SURRENDER) $ $ TRUST FUNDS $ $ $ RENTAL INCOME $ INTEREST/DIVIDENDS/MORTGAGE EXEMPT TRAINING $ $ $ NON-EXEMPT TRAINING $ $ $ STOCKS/BONDS EMPLOYMENT INSURANCE $ $ $ RRSP CPP WVA $ $ OTHER: $ BANKS NAME/ACCOUNT NO. $ $ $ 1. $ $ $ OAS/GIS $ $ $ 2. $ $ $ GFSS $ $ $ 3. $ $ $ WORKERS’ COMPENSATION $ $ $ PRIVATE RETIREMENT PENSION $ $ $ PRIVATE DISABILITY PENSION $ $ $ OTHER EARNED $ $ $ OTHER UNEARNED - CODE $ $ $ BASIC CANADA CHILD TAX BENEFIT $ $ $ FAMILY BONUS $ $ $ BC EARNED INCOME BENEFIT $ $ $ NO YES ALL FAMILY ASSETS AND THEIR CURRENT VALUE RECEIVED BY: YES NO SEEKING EMPLOYMENT? IS THERE AN OUTSTANDING WARRANT FOR YOUR ARREST ISSUED UNDER THE IMMIGRATION AND REFUGEE PROTECTION ACT (CANADA) OR ANY OTHER ENACTMENT OF CANADA IN RELATION TO AN OFFENCE FOR WHICH A PERSON MAY BE PROSECUTED BY INDICTMENT? BOARDER NO COMMENTS ON ABOVE ASSETS: ASSETS DISPOSED OF: MONTHLY SHELTER EXPENSES ROOM & BOARD PRIVATE $ RENT SHARED $ HEAT $ TAXES $ ROOM & BOARD PARENT/CHILD $ NET MORTGAGES $ PHONE (BASIC RATE) $ PROPERTY INSURANCE $ RENT $ HYDRO $ OTHER UTILITIES $ TOTAL $ AMOUNT ARE YOU RECEIVING HELP WITH THE ABOVE EXPENSES? IF SO, FROM WHOM? INITIALS OF APPLICANT(S) SD 0080(10/08/25) DATE $ INITIALS OF WITNESS DISTRIBUTION: COPY 1 - FILE DATE COPY 2 - APPLICANT Page 1 of 2

APPLICATION FOR INCOME ASSISTANCE (Part 2) APPLICATION FOR DISABILITY ASSISTANCE (Part 2) Applicant 1 Last Name First Name Attending School Full Time or Registered? YES Applicant 2 Last Name Attending School Full Time or Registered? First Name YES Dependants Last Name First Name Relationship NO Birthdate (YYYY MMM DD) % of Time Residing with Parent NO Primary Parent Sam ple YES NO YES NO MEDICAL SERVICES PLAN (MSP) CLIENT RELEASE • I agree to abide by the terms and conditions of MSP and declare that I, and any persons covered with me are residents of British Columbia. • I understand that practitioners who provide service(s) under MSP are required under the Medicare Protection Act to release information relative to those services to MSP to support claims for benefits. • I declare that all information provided is true and I understand that the Ministry of Health Services and/or Health Insurance BC may verify this information with immigration authorities, law enforcement authorities and other public authorities, agencies and persons as appropriate. Personal information provided to MSP is collected under the authority of the Medicare Protection Act. The information will be used to determine residency in British Columbia and determine eligibility for provincial health care benefits. If you have any questions about the collection of this information, contact a Health Insurance BC client service representative at 1 -800 -663 -7100. Personal information is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act and may be disclosed only as provided by that Act. SIGNATURE OF APPLICANT 1: DATE: YYYY MMM DD SIGNATURE OF APPLICANT 2: DATE: YYYY MMM DD DECLARATION: I declare that all the information I have provided in Part 1 and Part 2 of the application process is true and complete. I understand the accuracy of the information I provide will be checked by comparing it against information held by other governments, public bodies, private agencies and individuals. The BC government may verify and obtain information to confirm my eligibility or the eligibility of my dependants. I have read and understand the sections entitled ‘BC Government’s Responsibilities’, ’My Rights’, and ‘My Responsibilities’. I give permission to the organizations and individuals listed in Part 1 and Part 2 of this application to release, to employees of the ministry, information for the purpose of verifying and determining my eligibility or the eligibility of my dependants for assistance. SIGNATURE OF APPLICANT 1: SIGNED AT: IN THE PROVINCE OF BRITISH COLUMBIA DATE: YYYY MMM DD SIGNATURE OF APPLICANT 2: IN THE PROVINCE OF BRITISH COLUMBIA YYYY MMM DD SIGNATURE OF WITNESS: IN THE PROVINCE OF BRITISH COLUMBIA YYYY MMM DD DOCUMENTS SEEN: SD 0080(10/08/25) FACILITY NAME DISTRIBUTION: COPY 1 - FILE COPY 2 - APPLICANT FACILITY NUMBER Page 2 of 2