INCOME ASSISTANCE MONTHLY RENEWAL DECLARATIONS

INCOMPLETE SUBMISSIONS WILL NOT BE ACCEPTED

IF YOU REQUIRE CONTINUED INCOME ASSISTANCE, PLEASE COMPLETE THIS FORM AND RETURN TO COMMUNITY SERVICES OFFICE, 1900 QUAIL LAKE BEFORE DUE DATE EACH MONTH.

* MUST BE RETURNED BY:

* NEXT CHEQUE PICK UP DATE:

* 1. ARE YOU STILL IN NEED OF INCOME ASSISTANCE? YES
NO

* 2. HAS YOUR MARITAL/EMPLOYMENT SITUATION CHANGED? YES
NO

* IF YES, EXPLAIN:

* 3. LIST ANY CHANGES IN YOUR LIVING SITUATION (E.G. ADDRESS CHANGE, RENT, ETC.):

* 4. ARE YOU REGISTERED WITH THE WFN EMPLOYMENT CENTRE? YES
NO

* 5. HAVE YOU HAD ANY EARNED OR UNEARNED INCOME THIS MONTH? YES
NO

* 6. HAS THERE BEEN ANY CHANGE IN ASSETS? YES
NO

IF YES, COMPLETE:

EARNINGS:

CHILD TAX BENEFIT:

MAINTENANCE:

EI:

OTHER (SPECIFY):

TOTAL:

PROPERTY:

SIGN RENTAL:

LEASE:

OTHER (SPECIFY):

TOTAL:

* 7. IS THERE ANY CHANGE IN YOUR NUMBER OF DEPENDANTS OR THEIR SCHOOL STATUS? YES
NO

IF YES, EXPLAIN:

APPLICANT: PLEASE FILL OUT THE FOLLOWING QUESTIONS

CIRCLE M/F, FILL IN AN AGE OF DEPENDANTS, CIRCLE EDUCATION: GRADE SCHOOL OR POST-SECONDARY

* APPLICANT 1. MALE
FEMALE

* AGE:

* GRADE/POST:

2. MALE
FEMALE

AGE:

GRADE/POST:

3. MALE
FEMALE

AGE:

GRADE/POST:

4. MALE
FEMALE

AGE:

GRADE/POST:

CHILDREN 1. MALE
FEMALE

AGE:

2. MALE
FEMALE

AGE:

3. MALE
FEMALE

AGE:

4. MALE
FEMALE

AGE:

5. MALE
FEMALE

AGE:

I DECLARE THAT THIS IS A TRUE STATEMENT CONCERNING MY MONTHLY INCOME, ASSETS, MARITAL, EMPLYMENT AND FAMILY STATUS. I GIVE PERMISSION FOR THIS INFORMATION TO BE VERIFIED AND I CONSENT TO A REPORT BEING OBTAINED FOR ANY REPORTING AGENCY FOR THAT PURPOSE.

PRINT NAME CLEARLY:

DATE:

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