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MONTHLY REPORT
TO CONTINUE TO RECEIVE ASSISTANCE: COMPLETE THIS FORM AND SUBMIT TO THE MINISTRY BY THE 5TH OF NEXT MONTH, OR ONLINE
THROUGH YOUR MY SELF SERVE ACCOUNT (MYSELFSERVE.GOV.BC.CA)
Notice: Information on this form is collected under the authority of the Employment and Assistance Act and Regulation and the Employment and Assistance for Persons with Disabilities
Act and Regulation and will be used for verification of continuing eligibility for assistance. The accuracy of the information provided on this form will be checked by comparing it against
information held by other provincial, federal and private agencies. Collection, use and disclosure of the information is as authorized by the Freedom of Information and Protection of
Privacy Act. If you have questions about the collection, use or disclosure of this information, contact the ministry.
Declaration: I understand that the ministry may disclose this information to verify continuing eligibility for assistance under the above Acts and Regulations. I declare that all of the
information provided on this form to the Ministry of Social Development and Social Innovation is true and complete.
APPLICANT 1 SIGNATURE DATE
PRINT NAME
TELEPHONE SOCIAL INSURANCE NUMBER
APPLICANT 2 SIGNATURE DATE
PRINT NAME
TELEPHONE SOCIAL INSURANCE NUMBER
NEXT CHEQUE
ISSUE
BENEFIT MONTH TOTAL ALLOWANCE SHELTER PORTION INCOME DECLARED INCOME DEDUCTED OTHER DEDUCTIONS TOTAL CHEQUE
CASE ID CASELOAD
SINCE YOUR LAST DECLARATION:
HAS YOUR FAMILY UNIT RECEIVED OR DISPOSED OF ANY ASSETS? YES
NO
Applicant 1 Applicant 2
ATTENDING / ENROLLED IN SCHOOL / TRAINING? YES
NO
YES
NO
ARE YOU LOOKING FOR WORK? YES
NO
YES
NO
HAVE YOU MOVED OR ENTERED A FACILITY? YES
NO
YES
NO
ARE YOU STILL IN NEED OF ASSISTANCE? YES
NO
ANY CHANGES TO YOUR SHELTER COSTS? YES
NO
ANY CHANGES IN DEPENDANTS OR PERSONS LIVING IN THE HOME? YES
NO
Applicant 1 Applicant 2
ANY EMPLOYMENT CHANGES?
YES
NO
YES
NO
ANY OUTSTANDING WARRANTS FOR YOUR ARREST?
YES
NO
YES
NO
DECLARE ALL INCOME (Submit proof) ENTER “0” IF NONE
INCOME DESCRIPTION
AMOUNT
Applicant 1 Applicant 2
EMPLOYMENT INCOME
EMPLOYMENT INSURANCE
SPOUSAL SUPPORT / ALIMONY
CHILD SUPPORT
WORKBC FINANCIAL SUPPORT
STUDENT FUNDING (EG: LOANS, BURSARIES)
ROOM / BOARD INCOME
RENTAL INCOME
ALL OTHER INCOME OR MONEY RECEIVED
INCOME DESCRIPTION
AMOUNT
Applicant 1 Applicant 2
WORKERS' COMPENSATION
PRIVATE PENSIONS (EG: RETIREMENT, DISABILITY)
TRUST INCOME
OAS / GIS
CANADA PENSION PLAN (CPP)
TAX CREDITS (EG: GST CREDIT)
CHILD TAX BENEFITS
INCOME TAX REFUND
INCOME OF DEPENDENT CHILDREN
PLEASE EXPLAIN ALL CHANGES INCLUDING INCOME:
HR0081 (15/06/26) OPC 7530903053 (250/Pk)