Sample APPLICATION FOR INCOME ASSISTANCE (Part 2) APPLICATION FOR DISABILITY ASSISTANCE (Part 2) APPLICANT 1 LAST NAME FIRST NAME SIN BIRTHDATE MARITAL STATUS (YYYY MMM DD) DATE SEPARATED/DIVORCED (IF APPLICABLE) APPLICANT 2 LAST NAME FIRST NAME SIN BIRTHDATE (YYYY MMM DD) ADDRESS POSTAL CODE TELEPHONE ( ) IF SEPARATED OR DIVORCED, HAVE YOU APPLIED FOR FINANCIAL SUPPORT FROM YOUR SPOUSE? YES, STATE AMOUNT $ NO, GIVE REASON ALL OTHER PERSONS LIVING IN HOUSEHOLD EXCLUDING APPLICANT(S) APPLICANT 1 APPLICANT 2 RELATIONSHIP DEP DATE MOVED TO CANADA YES NO BIRTHDATE (YYYY MMM DD) YYYY MMM DD YYYY MMM DD DATE MOVED TO B.C. YYYY MMM DD YYYY MMM DD MOVED FROM (PROVINCE/COUNTRY) CANADIAN CITIZEN? YES NO YES NO ELIGIBLE UNDER LMDA? EXPLANATION FOR NOT SEEKING EMPLOYMENT YES NO YES NO HAVE YOU FILED AN INCOME TAX RETURN FOR THE PREVIOUS TAX YEAR? If you are completing this form after June 30th, the previous tax year is last year, otherwise it is the year before last year. APPLICANT 1 APPLICANT 2 SEEKING EMPLOYMENT? YES NO YES NO YES NO YES NO IS THERE AN OUTSTANDING WARRANT FOR YOUR ARREST ISSUED UNDER THE IMMIGRATION AND REFUGEE PROTECTION ACT (CANADA) OR ANY OTHER ENACTMENT OF CANADA IN RELATION TO AN OFFENCE FOR WHICH A PERSON MAY BE PROSECUTED BY INDICTMENT? YES NO YES NO ALL MONTHLY FAMILY INCOMES RECEIVED BY: ALL FAMILY ASSETS AND THEIR CURRENT VALUE OWNED BY: Sample TAKE HOME PAY (NET EARNINGS) $ APPLICANT 1 APPLICANT 2 DEPENDANTS APPLICANT 1 APPLICANT 2 DEPENDANTS $ $ CASH ON HAND $ $ $ SUPPORT OR MAINTENANCE $ $ $ 1ST VEHICLE $ $ $ ROOMER $ $ $ 2ND VEHICLE $ $ $ BOARDER $ $ $ RECREATIONAL VEHICLE $ $ $ RENTAL INCOME $ $ $ PROPERTY (NOT INCLUDING HOME) $ $ $ INTEREST/DIVIDENDS/MORTGAGE $ $ $ LIFE INSURANCE (CASH SURRENDER) $ $ $ EXEMPT TRAINING $ $ $ TRUST FUNDS $ $ $ NON-EXEMPT TRAINING $ $ $ STOCKS/BONDS $ $ $ EMPLOYMENT INSURANCE $ $ $ RRSP $ $ $ OTHER: CPP $ $ $ $ $ $ BANKS NAME/ACCOUNT NO. WVA $ $ $ 1. 2. 3. $ $ $ OAS/GIS $ $ $ $ $ $ GFSS $ $ $ $ $ $ WORKERS’ COMPENSATION COMMENTS ON ABOVE ASSETS: $ $ $ PRIVATE RETIREMENT PENSION $ $ $ PRIVATE DISABILITY PENSION $ $ $ OTHER EARNED $ $ $ OTHER UNEARNED - CODE ASSETS DISPOSED OF: $ $ $ BASIC CANADA CHILD TAX BENEFIT $ $ $ FAMILY BONUS $ $ $ BC EARNED INCOME BENEFIT $ $ $ MONTHLY SHELTER EXPENSES ROOM & BOARD PRIVATE $ RENT SHARED $ HEAT $ TAXES $ ROOM & BOARD PARENT/CHILD $ NET MORTGAGES $ PHONE (BASIC RATE) $ PROPERTY INSURANCE $ RENT $ HYDRO $ OTHER UTILITIES $ TOTAL $ ARE YOU RECEIVING HELP WITH THE ABOVE EXPENSES? IF SO, FROM WHOM? AMOUNT $ INITIALS OF APPLICANT(S) DATE INITIALS OF WITNESS DATE SD0080(10/08/25) DISTRIBUTION: COPY 1 - FILE COPY 2 - APPLICANT Page 1 of 2

Sample MEDICAL SERVICES PLAN (MSP) CLIENT RELEASE APPLICATION FOR INCOME ASSISTANCE (Part 2) APPLICATION FOR DISABILITY ASSISTANCE (Part 2) Last Name First Name Attending School Full Time or Registered? Applicant 1 YES NO Last Name First Name Attending School Full Time or Registered? Applicant 2 YES NO Dependants Last Name First Name Birthdate (YYYY MMM DD) % of Time Residing with Parent Relationship Primary Parent YES NO YES NO YES NO YES NO YES NO MEDICAL SERVICES PLAN (MSP) CLIENT RELEASE Sample I agree to abide by the terms and conditions of MSP and declare that I, and any persons covered with me are residents of British Columbia. I understand that practitioners who provide service(s) under MSP are required under the Medicare Protection Act to release information relative to those services to MSP to support claims for benefits. I declare that all information provided is true and I understand that the Ministry of Health Services and/or Health Insurance BC may verify this information with immigration authorities, law enforcement authorities and other public authorities, agencies and persons as appropriate. Personal information provided to MSP is collected under the authority of the Medicare Protection Act. The information will be used to determine residency in British Columbia and determine eligibility for provincial health care benefits. If you have any questions about the collection of this information, contact a Health Insurance BC client service representative at 1-800-663-7100. Personal information is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act and may be disclosed only as provided by that Act. SIGNATURE OF APPLICANT 1: DATE: YYYY MMM DD SIGNATURE OF APPLICANT 2: DATE: YYYY MMM DD DECLARATION: I declare that all the information I have provided in Part 1 and Part 2 of the application process is true and complete. I understand the accuracy of the information I provide will be checked by comparing it against information held by other governments, public bodies, private agencies and individuals. The BC government may verify and obtain information to confirm my eligibility or the eligibility of my dependants. I have read and understand the sections entitled ‘BC Government’s Responsibilities’, ’My Rights’, and ‘My Responsibilities’. I give permission to the organizations and individuals listed in Part 1 and Part 2 of this application to release, to employees of the ministry, information for the purpose of verifying and determining my eligibility or the eligibility of my dependants for assistance. SIGNATURE OF APPLICANT 1: SIGNED AT: IN THE PROVINCE OF BRITISH COLUMBIA DATE: YYYY MMM DD SIGNATURE OF APPLICANT 2: IN THE PROVINCE OF BRITISH COLUMBIA YYYY MMM DD SIGNATURE OF WITNESS: IN THE PROVINCE OF BRITISH COLUMBIA YYYY MMM DD DOCUMENTS SEEN: FACILITY NAME FACILITY NUMBER Page 2 of 2 SD0080(10/08/25) DISTRIBUTION: COPY 1 - FILE COPY 2 - APPLICANT