Saskatchewan Income Support

Financial Review Declaration Box 2405 Stn. M

Regina, SK S4P 4L7
Phone: 1-866-221-5200
Email: income.supportss@gov.sk.ca

Your Information
Last Name First Name SIS Client Number
Abdirahman Usun CLN-004069036
Date of Birth (yyyy/mmm/dd) Box/Street Number & Name City/Town Postal Code
1967/01/01 1254 Degelman Dr Regina, Saskatchewan S4N7N4
Name of Spouse/Partner Spouse/Partner’s Date of Birth (yyyy/mmm/dd)
No spouse/partner

1. Do you have dependents living with you? * Yes * No If yes, complete the following:

Date of Birth Are you receiving Canada Child

Last Name, First Name (yyyy/mmm/dd) Benefit (CCB) for this child?

* Yes * No
* Yes * No
* Yes * No
* Yes * No
a. If you are not receiving Canada Child Benefit (CCB) for any child dependents living with you, have you applied
for each child? *
Yes No *
b. If yes, when did you apply? Indicate date(s): _____________________________________________________

c. If no, why have you not applied? _______________________________________________________________

2. Do you or anyone in your household have money or investments (such as money in the bank, RRSPs,
other investments)? Yes * *
No If yes, complete the following. You must provide statement copies.

What is the Financial

Asset Description Value of Asset In Whose Name is the Asset Institution?

3. Do you or anyone in your household have assets (such as property or vehicles)? * Yes * No
If yes, complete the following:

Asset Description Registered Owner Address or Legal Description *Equity Value

* Equity value is the present value of the asset minus what you owe.

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 4. Have you sold, traded, transferred to given away any assets (such as cash, savings bond, home, land, etc.) since your last
financial review? * Yes * No If yes, complete the following:

Asset description Date of disposal Amount received How money received was spent

5. Have you or your spouse/partner received any income from any source since you applied or last completed a financial
review (such as wages, taxes, child support, student loan, income tax refund, CCB, pension, employment insurance)?
* Yes * No If yes, complete the following:

Source of income Date received Name of person who received it Amount

6. Are you or your spouse/partner expecting income from any source (such as wages, taxes, child support, student loan,
income tax refund, CCB, pension, employment insurance)? *
Yes *
No If yes, complete the following:

Source of income Date received Name of person who received it Amount

7. Do you have a formal arrangement to live, stay or sleep somewhere? * Yes * No

Supporting documentation is required. If not previously provided, please include your tenancy agreement.

8. Do you pay to heat your home with electric heat, propane, oil, wood or coal? * Yes * No
Supporting documentation is required. Please include current receipts.

You are expected to use direct deposit for your benefits. Please complete the Direct Deposit Form if you are not currently
receiving your benefits by direct deposit. If you are unable to establish direct deposit for your benefits, contact the program
at the above number.

Review and sign the Declaration on the following pages.

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Declaration

I state the information I have provided is true, correct and complete and that I have not withheld any information which may
impact my income assistance benefits and/or eligibility. I understand I may be subject to criminal prosecution if I withhold
information or provide false or misleading information.

My Rights
I/We have the right to:
• have my/our personal information and personal health information protected, in accordance with The Freedom of
Information and Protection of Privacy Act and The Health Information Protection Act;
• request a copy of the information I provide to the Ministry of Social Services about myself;
• apply for a review of the assessment of eligibility or the calculation of income support;
• be treated with respect in all interactions with Ministry of Social Services staff;
• withdraw my consent at any time by contacting the Ministry of Social Services at 1-866-221-5200. This withdrawal will
take effect the date I notify the Ministry and will not be retroactive;
• contact the Ministry of Social Services Privacy Officer if I/we have questions or concerns related to my/our privacy rights
(email access.privacy@gov.sk.ca or call 306-787-0227).

My Responsibilities
I/We agree to:
  
• report all changes as they occur, or on the next business day, to the Ministry of Social Services. This includes address
changes, changes in the number of my family members, any money I or my partner/spouse may get (including e-
transfers), start and end dates of any training, and any other changes that may affect my/our eligibility for income
assistance benefits;
• make every effort to support myself, including looking for employment or training to the best of my abilities;
• follow up on all sources of income, including child support and benefits available through other government programs;
• create, participate and be accountable to an agreed upon case plan with the Ministry of Social Services; and
• update any changes to my/our email account with the Ministry of Social Services.
I/We understand:
• The Ministry of Social Services collects and uses my/our personal information and personal health information to provide
me/us with services and benefits I/we need. In particular, I/we understand and agree to the following:
- The Ministry of Social Services will subtract any payments I get that I am not entitled to from future income support
payments;
- The Ministry of Social Services may collect overpayments owed to another ministry or program and subtract from
any future income support payments;
- I am responsible for repaying any overpayments I get if I fail to report any changes to my or my spouse’s/partner’s
circumstances;
- I am responsible for repaying any outstanding overpayment to the Ministry of Social Services even when I am no
longer eligible for income support;
- The Ministry of Social Services will keep and dispose of the information I provide in my application according to
approved records retention schedules, as required by The Archives and Public Records Management Act;
- The Ministry of Social Services may ask for additional personal information for the purposes of data analytics. I/We
understand I/we can choose whether to provide this information and that my/our decision will not impact eligibility
for services or benefits; and
- The Ministry of Social Services will communicate with me using the email address linked to my Saskatchewan.ca
account. I understand I am responsible for checking this email regularly.

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 • I am responsible for providing all required verification documents as required and within the stated timelines.
• I will be respectful in all interactions with Ministry of Social Services staff. I will be held accountable for any
aggressive, violent or inappropriate actions.

Declaration
Usun Abdirahman
I/We, _____________________________ and _____________________________ do solemnly declare that all of the information
in this application is true and complete. I/We make this solemn declaration believing it to be true, knowing that it is of the same
force and effect as if made under oath.

I/We understand that I/we may be liable to criminal prosecution for withholding information or providing false or misleading
information.

✔ Yes, I Agree. Yes, Spouse Agrees

_________________________________________________ _________________________________________________
Client Signature Spouse/Partner Signature

2023/01/04
_________________________________ _________________________________
Date Date

Client Consent

I/We give consent to the Ministry of Social Services to collect, use and disclose my or my family’s Social Insurance Number(s),
Health Services Number(s) and to determine eligibility for income support.

I/We give consent to the Ministry of Social Services to collect, use and disclose information provided voluntarily (such as Driver’s
License or Non-Driver’s ID number(s), gender etc.).

I/We give consent to the Ministry of Social Services to collect, use and disclose information or documents required to confirm my
or my family’s eligibility and for the purposes of case or individualized planning. Such planning activities may include developing
money management skills, accessing services from third parties, obtaining and maintaining utility services, career training and
assistance with job applications. I/We understand this information includes money received from any source (including e-
transfers) to verify assets and to verify relationship status. Examples include, but are not restricted to, information or documents
from:

• Employment and Social Development Canada (Employment Insurance Program);

• Workers’ Compensation Board;
• Saskatchewan Government Insurance;
• any bank, credit union or other financial institution;
• utility companies (including, but not limited to, SaskPower and SaskEnergy);
• any landlord, past employers and providers of pre-employment services or programs for the time period I am/we are
in receipt of Saskatchewan Income Support; and
• other divisions within the Ministry of Social Services (including but not limited to, Child and Family programs and
Disabilities programs.

I/We give consent to the Ministry of Social Services to share my or my family’s information to third parties and to collect and use
information from those third parties where the information is necessary to verify and confirm eligibility for income assistance, or
to assist in providing case or individualized planning. I understand my information (name, date of birth and address) will be
shared with SaskPower and SaskEnergy to identify individuals that receive services from the Ministry and either/or SaskPower
and SaskEnergy, for the purpose of case or individualized planning. I understand my information (name, date of birth and
address) will be shared with 3rd parties contracted by the Ministry to assess disability impact when determining eligibility for the
Saskatchewan Assured Income for Disabilty program (if applicable). Other examples of third parties include, but are not
restricted to:

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 • SaskAbilities;
• Canada Revenue Agency;
• Ministry of Advanced Education;
• Ministry of Education;
• Ministry of Immigration and Career Training;
• education and career training institutions and centres;
• Workers’ Compensation Board;
• Canada Pension Plan; and
• First Nation Bands.

I/We give consent to the Ministry of Social Services to use and disclose my information (including information provided
voluntarily) for research and evaluation purposes within the Ministry. I/We understand this may include information collected
from me or other sources. I/We give consent to the Ministry of Social Services to use my data in research and evaluation projects
that may involve my information held by Social Services being combined with other government ministries and agencies.

In the event that the Ministry of Social Services pays for my funeral/cremation, I/we authorize the Ministry to apply for my
Canada Pension Plan - Death Benefit upon my death.

Canada Revenue Agency requires we provide you with a specific consent statement.

I/We authorize the Canada Revenue Agency to release income and expense information and related identifying information
about me or my family from income tax records to the Ministry of Social Services. The Ministry will use the information only to
determine and verify my or my family’s eligibility for income support through the Saskatchewan Income Support program, and
for collecting overpayments of income support under that program that I or my family were not entitled to. The Ministry will not
share this information to any person or organization without my or my family’s written approval or unless required to be disclosed
by operation of law (for example: subpoenas or other legislative requirements to disclose information). This authorization is valid
for the taxation year of the application date and all following taxation years for which I/We request income support. I/We
understand that I or my family may withdraw this consent by writing to the Ministry of Social Services.

_________________________________________________ _________________________________________________
Client Signature Spouse/Partner Signature

2023/01/04
_________________________________ _________________________________
Date Date

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