Application Form For Hardship Payments Page 3

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CURRENT SOURCES OF INCOME
1. Employment Insurance:
a. Amount: __________________________________________________________________
b. Actual/Expected End Date: ___________________________________________________
c. If no EI, or EI terminated, reason(s):
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
2. Social Assistance:
a. Type of Social Assistance: ____________________________________________________
b. Commencement Date: _______________________________________________________
c. Amount: __________________________________________________________________
d. Actual/Expected End Date:
__________________________________________________________________________
e. If social assistance is being terminated, reason(s) why:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
3. Other Sources of Income (including LTD, other disability payments, other employment, pension,
workers’ compensation, etc.):
________________________________________________________________________________
a. Amount: ___________________________________________________________________
b. Actual/Expected End Date: ____________________________________________________
4. Provincial Drug Benefit Programs:
a. Have you applied for, or been granted, any provincial drug benefit program? If so, which
program?
__________________________________________________________________________
__________________________________________________________________________
b. What are the conditions of your receiving this benefit?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
c. Why does this benefit not cover your needs?
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________

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