1. 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

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 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