Application Form For Hardship Payments Page 4
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5. Other Extended Health and Dental Benefits:
a. Do you have access to other extended health and dental benefits through a family member
(i.e. a spouse)?
__________________________________________________________________________
b. If so, please explain how those benefits do not cover your needs:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
6. Other Sources of Income:
a. Gross yearly income of your spouse? ___________________________________________
PERSONAL CIRCUMSTANCES REQUIRING HARDSHIP PAYMENT
Medical expenses for self or dependent (including nature of expense, amount, whether can be
reimbursed from another source):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Other reason for immediate or urgent need for funds (for example, risk of loss of housing in the next 30
days):
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
I certify the contents hereof to be true and that I have obtained all necessary consents for the disclosures
set forth herein.
__________________________
___________________________
___________________
Witness
Signature
Date
The Monitor’s address, fax number and email address are:
FTI Consulting Canada Inc. in its capacity as Court Appointed Monitor of Sears Canada Inc. et al
TD South Tower
79 Wellington Street West
Suite 2010, P.O. Box 104
Toronto, Ontario M4K 1G8
Attention: Sears Employee Hardship Fund
Fax: (416) 649-8101
Email:
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