Income Assessment Form For Edmonton Zone Ambulatory Community Physiotherapy Page 3
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3Determination of Income Eligibility (Sections B and C)
Note: Low income eligibility is not applicable to full time students who are under the age of 25 and
currently covered by parental or guardian extended health benefit plans.
If you completed Section B or C, use the table below to determine if you are eligible for funded
physiotherapy services.
Section B: Use the total annual taxable income for yourself and your spouse/partner,
based on the most recent tax year Notice of Assessment.
Section C: Use the total gross income for yourself and your spouse/partner for the last
three months as calculated on the table under Section C.
Section B
Section C
*
Family Size
3 Month Total Gross Income
**
Annual Taxable Income
1
$23,861
$5,965
2
$29,706
$7,427
3
$36,520
$9,130
4
$44,340
$11,085
5
$50,290
$12,573
6
$56,718
$14,180
7+
$63,147
$15,787
*
Family Size includes the applicant, their spouse or common-law partner
and the number of dependent children residing in the household.
Source: 2013 pre-tax Statistics Canada Low Income Cut-offs (LICO) – updated annually
**
If your income is equal to or less than the amounts indicated above, you and/or your family
members are eligible to receive up to four extra funded physiotherapy services from the Ambulatory
Community Physiotherapy program (Edmonton Zone).
Income eligible for further funded physiotherapy services
Income exceeds limits - not eligible for further funded physiotherapy services
If you need help with your taxes: The Canada Revenue Agency operates the Community Volunteer Income
Tax Program to assist low income Canadians with completing their income tax returns at no cost. For
information or to get a copy of your Notice of Assessment, call the local office or 1-800-959-8281, or visit their
website at
The personal information being collected will be used to determine and/or verify your eligibility to participate in
an Alberta Health Services (Edmonton Zone) program. The personal information is collected and used under
Section 33(c) of the Freedom of Information and Protection of Privacy Act of Alberta. If you have any questions
about the collection of your personal information, contact the Ambulatory Community Physiotherapy program in
Edmonton at (780) 735-3342.
Effective September 1, 2014
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