Income Assessment Form For Edmonton Zone Ambulatory Community Physiotherapy (Page 2 of 3) in pdf

Income Assessment Form For Edmonton Zone Ambulatory Community Physiotherapy Page 2

Section B – Low Income

If you are not receiving assistance from a Government program listed in Section A, eligibility is

based on your total annual taxable income from your latest Notice of Assessment (from the most

recent tax year) for yourself and your spouse/partner. You may be asked to provide documentation

of proof of income. If you do not have this information, you must fill out Section C. Refer to Page 3

to determine your eligibility.

1. Taxable income (line 260) of your Notice of Assessment (Form T452)

2. Taxable income (line 260) of your spouse/partner’s Notice of Assessment

(Leave blank if you do not have a spouse/partner)

3. Total annual taxable income of your family (Add numbers 1 and 2)

I declare that I have provided accurate and complete information about the total annual

taxable income of my family. I know that it is against the law to give false information.

Client/Guardian Signature

Date (dd/mmm/yyyy)

Section C – Temporary Hardship

Complete this section if you do not have a Notice of Assessment or if you have had recent financial

difficulty. You may be asked to provide documentation of proof of income. Include your total gross

income from all sources for the last 3 consecutive months, excluding child tax credits, student loans

or GST credits, for both yourself and your spouse/partner. (Gross income is your total income

before taxes or deductions.) Refer to Page 3 to determine your eligibility.

Your Spouse/Partner’s

Total Monthly Gross Income for the

Your Income for the

Month/Year

Monthly Income for the

Family

Month You Listed

(Applicant plus Spouse/Partner)

Total gross income for the last three (3) months:

I declare that I have provided accurate and complete information about the total monthly

gross income, excluding child tax credits, student loans or GST credits, of my family. I

know that it is against the law to give false information.

Client/Guardian Signature

Date (dd/mmm/yyyy)

Effective September 1, 2014

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Income Assessment Form For Edmonton Zone Ambulatory Community Physiotherapy Page 2