form isp 2530 - service canada forms · service canada protected b (once completed) terminal...

Service Canada

A Guide to Help you Complete your Application for Canada Pension Plan Disability Benefits

Is this Form for You?This condensed application has been designed for individuals who have a terminal illness. This form is for you if you answer YES to either of the following questions:

- Have you been told by your doctor or health care provider you have a terminal illness? YES or NO

- Has the individual you are assisting to apply been told they have a terminal illness by their doctor or health care provider? YES or NO

If you answer NO to either question, do not use this form. You will need to complete form SC ISP-1151 - Application for Canada Pension Plan Disability Benefits and related documents at www.servicecanada.gc.ca.

How to Complete this ApplicationUse a pen and complete the form as clearly as possible. If you need additional space, use a separate sheet. On each separate sheet include your Social Insurance Number, the box number to which you are responding and your signature. Make sure to attach all separate sheets to this form.

Section A: Information that you provide in question 3 will be used to determine your child(ren)'s eligibility for the disabled contributor's child benefit. We may use the information you provide to contact a custodial parent of your child(ren), where applicable, to assess the eligibility of the child(ren) and to determine who should receive the child benefit on behalf of the child(ren). We may also use information you provide to contact your child(ren) between the ages of 18 to 25 in order to assess their eligibility for the child benefit.

We will not share the details of your disability with a custodial parent or your child(ren).

If you have children born after 1958, the child-rearing provision may help you receive a higher Canada Pension Plan benefit amount. The amount of benefits paid under the Canada Pension Plan is based on how long and how much you contributed to the Plan while you were working and, in some cases, your age when your benefit begins. Periods of time when you had no or low earnings usually result in a lower benefit amount.

If you were not working or had low earnings while caring for a child under the age of seven, the child-rearing provision can be used to exclude these time periods from the calculation of your benefit. This may help you qualify for benefits or increase the benefit amount you can receive.

Section B: An authorized person can be anyone who you have identified to give and receive information on your behalf. The authorized person cannot make decisions on your behalf. If you are granted Canada Pension Plan Disability Benefits, the authorized person will not receive your payments.

A legal representative's authority, on the other hand, is determined by the content of a legal document. A legal representative has the authority to make decisions on your behalf, for example, apply for benefits. If you have a legal representative, they must provide the legal documents as proof of authorization e.g. Power of Attorney.

Section C: Important : Make sure that you or your legal representative sign this section indicating that you are applying for a disability benefit and, if applicable, a child benefit under the Canada Pension Plan. Not signing this section will cause a delay in your application.

It is an offence to make a false or misleading statement in an application for benefits. If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the Canada Pension Plan, or may be charged with an offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid.

SC ISP-2530A (2017-12-13) E 1 / 2 Disponible en français

Service Canada delivers Employment and Social Development Canada programs and services for the Government of Canada

Section D: At times, Canada Pension Plan requires additional information to make a decision about your eligibility. By signing this form, we are able to obtain the necessary information.

Section E: This should be completed by the physician who is most familiar with your medical condition. Ensure that you complete the box for your Social Insurance Number before handing the form to your physician. Service Canada will pay up to $85.00 directly to your physician for the completion of the medical report.

Privacy Notice Statement

The information you provide is collected under the authority of the Canada Pension Plan (CPP) and will be used to determine your eligibility for benefits. The Social Insurance Number (SIN) is collected under the authority of the CPP and in accordance with the Treasury Board Secretariat Directive on the SIN, which lists the CPP as an authorized user of the SIN. The SIN will be used as a file identifier and to ensure your exact identification so that contributory earnings can be correctly applied to your record to allow benefits and entitlements to be accurately calculated. Completion is voluntary; however, failure to complete this form may result in you not being considered for a benefit.

The information you provide may be shared with the Department of Employment and Social Development Canada (ESDC), with any federal institution, provincial authority or public body created under provincial law with which the Minister of ESDC may have entered into an agreement, and / or with non-governmental third parties for the purpose of administering the CPP, other acts of Parliament and federal or provincial law as well as for policy analysis, research and / or evaluation purposes. The information may be shared with the government of other countries in accordance with agreements for the reciprocal administration or operation of that law and of the Canada Pension Plan.

The information you provide may be used and / or disclosed for policy analysis, research and / or evaluation purposes. However, these additional uses and / or disclosures of your personal information will never result in an administrative decision being made about you.

Your personal information is administered in accordance with the Privacy Act and other applicable laws governing the protection of personal information under the control of Service Canada. Under the CPP and the Privacy Act you have the right to look at the personal information and request correction - about you in your file. We will keep this information in Personal Information Bank ESDC PPU 146 (Retirement, Disability, Survivors and Death benefits). You can ask to see your file by contacting a Service Canada office. Instructions for requesting personal information are provided in the government publication Info Source, which is available at: www.infosource.gc.ca. Info Source may also be accessed online at any Service Canada Centre.

Other Benefits Offered by Service CanadaYou may be eligible for Sickness Benefits from Employment Insurance (EI). Sickness Benefits may be paid up to 15 weeks to a person who is unable to work because of sickness, injury or quarantine. As well, EI offers Compassionate Care Benefits which are paid to a person who has to be away from their work to provide care or support to a gravely ill family member at risk of dying within 26 weeks. You or a family member can obtain an application for either Sickness Benefits or Compassionate Care Benefits at www.servicecanada.gc.ca or at your local Service Canada office.

Ensure that all sections of the application form have been completed.

Service Canada will contact you or your physician if further information is required.

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Service Canada

Service Canada Offices Disability

Mail your forms to: The nearest Service Canada office listed below. From outside of Canada: The Service Canada office in the province where you last resided. Need help completing the forms? Canada or the United States: 1-800-277-9914 All other countries: 613-957-1954 (we accept collect calls) TTY: 1-800-255-4786 Important: Please have your social insurance number ready when you call.

NEWFOUNDLAND AND LABRADOR Service Canada PO Box 9430 Station A St. John's NL A1A 2Y5 CANADA

NOVA SCOTIA AND PRINCE EDWARD ISLAND Service Canada PO Box 1687 Station Central Halifax NS B3J 3J4 CANADA

NEW BRUNSWICK AND QUEBEC Service Canada PO Box 250 Fredericton NB E3B 4Z6 CANADA

ONTARIO Service Canada PO Box 2020 Station Main Chatham ON N7M 6B2 CANADA

MANITOBA AND SASKATCHEWAN Service Canada PO Box 818 Station Main Winnipeg MB R3C 2N4 CANADA

ALBERTA / NORTHWEST TERRITORIES AND NUNAVUT Service Canada PO Box 2710 Station Main Edmonton AB T5J 2G4 CANADA

BRITISH COLUMBIA AND YUKON Service Canada PO Box 1177 Station CSC Victoria BC V8W 2V2 CANADA

Disponible en français

SC ISP-3501-DSB (2016-05-09) E

Service Canada

PROTECTED B (once completed)

Terminal Illness Application for a Disability Benefit Under the Canada Pension Plan

PLEASE TYPE OR PRINT CLEARLY using blue or black ink.

Section A - Applicant Information1. Information about you

Mr. Mrs. Ms. Other Male FemaleSocial Insurance Number

Given name Middle name or initial Family name

Language preference

English

French

Single

Married

Common-law

Divorced

Separated

Surviving spouse or common-law partner

Date of birth (YYYY-MM-DD)

Place of birth (City / Town, Province / Territory, or country if other than Canada) IMPORTANT: You do not need to provide proof of birth

with your application. However, the Canada Pension Plan has the right to request proof of birth at any time.

If you have indicated separated or divorced above, provide the following:Date of marriage or common-law union

(YYYY-MM-DD)Date you last lived with your spouse or common-law partner

(YYYY-MM-DD)

Home address (number, street, apartment, rural route) City or town

Province or territory Country (if other than Canada) Postal code

Mailing address (if different from home address) City or town


Telephone number (day) Alternate telephone number

2. Payment informationDirect deposit in Canada: Complete the boxes below with your banking information.Branch Number (5 digits)

Institution Number (3 digits)

Account Number (maximum of 12 digits)

Name(s) on the account Telephone number of your financial institution

Direct deposit outside Canada:For direct deposit outside Canada, please contact us at 1-800-277-9914 from the United States and at 613-957-1954 from all other countries (collect calls accepted). The form and a list of countries where direct deposit service is available can be found at www.directdeposit.gc.ca.

Service Canada delivers Employment and Social Development Canada programs and services for the Government of Canada

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Social Insurance Number:Information about your child(ren) - This information will be used to determine your child(ren)'s eligibility for the disabled contributor's child benefit. (If you need additional space, use a separate sheet. Each separate sheet that you submit must include your Social Insurance Number, the box number to which you are responding and your signature. Make sure to attach all sheets to this form.)

3A. Child(ren) under age 18Do you have children under the age of 18 in your custody and control?

Yes No If yes, provide the following information for each child:

Child's full name at birth Place of birth (City or town, province or territory, country)

Social Insurance Number (if available)

Relationship

Natural child Legally adopted Other

Date of birth YYYY-MM-DD



Relationship





Relationship



Do you have children under the age of 18, in the custody and control of someone else?

Yes No If yes, provide the following:

Note: If you are found to be eligible for Canada Pension Plan Disability Benefits, we will contact the custodial parent of your child(ren) listed below to provide them an application for the children's benefits. We will not disclose any information about your disability.

First child's full name Custodian's full name

Address (number, street, apartment, rural route) City or town


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Social Insurance Number:Second child's full name Custodian's full name

Address (number, street, apartment, rural route) City or town


3B. If you have children between the ages of 18 and 25 attending school, college or university now or within the past 11 months, list below.

Note: If you are found to be eligible for Canada Pension Plan Disability Benefits, we will contact your children listed below to provide them an application for the children's benefits. We will not disclose any information about your disability.

Given name of child Middle name or initial Family name









3C. On behalf of any of the child(ren) listed in this application, has an application previously been made, or have benefits been received from:

Applied Received

Canada Pension Plan Yes No Unknown Yes No Unknown

Quebec Pension Plan Yes No Unknown Yes No Unknown

If yes, indicate under which Social Insurance Number(s).

Social Insurance Number Social Insurance Number

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Social Insurance Number:

4A. Child(ren) born after 1958(Please read the information sheet for additional details on the child-rearing provision for children born after 1958.) You may receive a higher pension amount if you have children born after 1958.

Information about your child(ren)List all children born after December 31, 1958.

Child's full name

Child's Social

Insurance Number

Child's date of birth

YYYY-MM-DD

If the child was born outside of Canada, tell us the date the child entered Canada

YYYY-MM-DD

Were you the primary caregiver for these children from birth until age seven? Yes No

If no, list any periods of time where you were not the primary caregiver and provide the reason:

FROM:YYYY-MM

TO:YYYY-MM

Reason:

FROM:YYYY-MM

TO:YYYY-MM

Reason:

Did you or your spouse or common-law partner receive Family Allowance or Canada Child Tax Benefit payments for the above mentioned child(ren)?

Yes No

If yes, indicate who received the benefits: I did My spouse or common-law partner did

List any periods of time while the children were under the age of seven and when you did not receive Family Allowance or Canada Child Tax Benefit payments and provide a reason. Do not list periods of time when you were eligible for the Canada Child Tax Benefit but did not receive it because your family income was too high.

FROM:YYYY-MM

TO:YYYY-MM

Reason:

FROM:YYYY-MM

TO:YYYY-MM

Reason:

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4B. Waiver of rights to the child-rearing provision

To be completed only by the person who received Family Allowance payments under the Family Allowance Act and who wishes to waive all rights to the child-rearing provision in favour of the spouse who remained at home and who was the primary caregiver for the child(ren).

I declare that, for the child(ren) indicated above and on any additional sheets, I have not and will not claim for the child-rearing provision for the period(s) accredited to my spouse.

Name Social Insurance Number

Signature Date (YYYY-MM-DD) Telephone number during the day

5. Work history: Provide the following dates:

When you could no longer do your regular job because of your medical condition or illness: (YYYY-MM-DD)

When you stopped working completely: (YYYY-MM-DD)

Name of most recent employer: Telephone number

What kind of work did you do?

Have you worked in another country? No (Go to question 6) Yes (Complete below)

Country Social Security Identification Number (if known)

Period of employment From (YYYY-MM) To (YYYY-MM)

If you now live outside of Canada, in which Canadian city or town, province or territory did you last reside? In which year did you leave Canada?

City or town Province or territory Year

6. Education (Indicate highest level completed)

Primary: Secondary:less than 2 years2 years or moreDiploma

Community College:1 year2 yearsDiploma

University:1 year2 years3 yearsDegreeOther: (please explain):

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7. Medical informationDescribe the medical condition or illness that prevents you from working. If you do not know the medical names, describe in your own words.

What effect does your medical condition or illness have on your everyday activities?

Date when your symptoms began? (YYYY-MM)

Full name of the physician or nurse practitioner who is most familiar with your medical condition:

Telephone number

Full name of the physician or nurse practitioner completing the medical report (Section E) if different than above:

Telephone number

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Section B - Consent to communicate informationDo you wish to name a person (such as your spouse, common-law partner, other family member or friend) to communicate on your behalf with Service Canada about your Canada Pension?

No (Go to Section C) Yes (Complete below)

I, , give my consent for employees of Service Canada to communicate with the person named below any personal information in my file about my Disability Benefit application under the Canada Pension Plan.

Your full name

I understand that this consent remains valid unless I cancel it in writing. I also understand that by signing this form I am giving the below named person the authority to give and receive personal information on my behalf. However, I am not giving the person the authority to make decisions on my behalf. As well, I understand that this consent is only valid if Service Canada receives this form within one year from the date I signed it. I also understand that this consent is revoked in the event of my death.

I request that Service Canada send all correspondence to the authorized person named below: Yes No

Note: If our records indicate that a legal representative, such as a Power of Attorney or Trustee, is authorized to act on your behalf, all communications will be made through that legal representative.

Information about the authorized person and their signature

I understand that I can communicate with Service Canada to give and receive personal information on behalf of the person named above. I also understand that I do not have the authority to apply for a benefit or to change the payment address on this person's behalf.

Authorized person's given name Middle name or initial Family name

Telephone number: Home Telephone number: Work Telephone number: Other

Mailing address (number, street, apartment, P.O. Box, rural route) City or town


Signature of authorized person Date (YYYY-MM-DD)

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Section C - Declaration and signature

I understand that it is an offence to make a false or misleading statement in an application for benefits.

I have read Section B and I concur that:

I wish to name the above person as an authorized person

I do not wish to have an authorized person

I hereby apply for a disability benefit and, if applicable, a child benefit under the Canada Pension Plan (CPP) and declare, that to the best of my knowledge and belief, all the information herein is true and complete. I realize that my personal information is governed by the Privacy Act and it can be disclosed where authorized under the CPP.

For legal representatives: I agree to notify Service Canada if and when I cease acting as the legal representative of the applicant and / or changes in the applicant's condition whereby the applicant is able to act on his / her own behalf. As well, I have enclosed proof of authorization e.g. Power of Attorney.

Signature of applicant / legal representative Date (YYYY-MM-DD)

To be completed by a witness only if the applicant signs with a mark "X".

I have read the contents of the application to the applicant, who appeared to fully understand them and who made his / her mark in my presence.

Given name of witness Middle name or initial Family name

Mailing address (number, street, apartment, P.O. Box, rural route) City or town


Signature of witness Date (YYYY-MM-DD)

Keep a photocopy of sections B and C for reference purposes when contacting Service Canada.

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PLEASE TYPE OR PRINT CLEARLY using blue or black ink. Social Insurance Number:

Section D - Consent for Service Canada to obtain personal informationGiven name Middle name or initial Family name

Address (number, street, apartment, P.O. Box, rural route) City or town


Telephone number (day) Alternate telephone number

Service Canada is authorized under Section 68 and 69 of the Canada Pension Plan (CPP) Regulations to receive personal (medical and non-medical) information about you to decide if you qualify or continue to qualify for CPP disability benefits. Your consent to permit Service Canada to obtain this information is necessary, should Service Canada need this information from persons and organizations listed below.I give Service Canada my consent to obtain personal information about me that would help decide if I qualify or continue to qualify for Canada Pension Plan disability benefits. For this reason, Service Canada may contact any of the following persons and organizations if necessary:

- Medical doctors, nurse practitioner, consultant specialist, or health-care professionals;- Educational institutions or other vocational agencies;- My accountant or book-keeper for information on self-employment;- Federal, provincial, territorial, or municipal government departments and agencies;- Provincial or territorial workers' compensation boards;- Financial institutions - for address updates only;- Medical facilities or hospitals;- Administrators of insurance plans;- Employers, former employers.

I give my consent to Service Canada to obtain medical and other personal information about me from all persons and organizations listed above. I understand that this information may help in determining if I qualify or continue to qualify for CPP disability benefits.

I do not give my consent to Service Canada to obtain medical and other personal information about me from all persons and organizations listed above.

I understand that my refusal means:- that Service Canada will make a decision based on the available information on my file;- if I am already receiving disability benefits, Service Canada may stop paying me the benefits; and- under certain circumstances, Service Canada can require that I provide the necessary information (CPP Regulations).

Signature of applicant / legal representative Date (YYYY-MM-DD)

To be completed by witness if signed with a mark "X" or by a representative of the applicant.I have read the contents of this section to the applicant, who appeared to fully understand and who made his / her mark in my presence.Given name of witness Middle name and initial Family name

Address (number, street, apartment, P.O. Box, rural route) City or town


Witness signature Date (YYYY-MM-DD)

This signed consent is valid for up to 3 years unless you cancel it in writing. A photocopy or fax of this completed form is as valid as the original.

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Service Canada


Medical Report GuideTo the Physician or Nurse Practitioner

Information

Your patient is applying for a Canada Pension Plan disability (CPP-D) benefit. This specific medical report is to be used for those individuals with a terminal illness. To assist us in determining eligibility, please complete this form.

A delay in the completion of this medical report may affect your patient's entitlement to benefits.

Please provide additional medical evidence (for example: lab results, specialist consultation reports, etc.) to support the diagnosis / prognosis.

It is an offence to make a false or misleading statement in an application for benefits.

Access to Personal Information

Pursuant to the Privacy Act, upon written request, Service Canada is obligated to provide the applicant or his / her representative with any information or records, including medical reports, contained in their file (Personal Information Bank ESDC PPU 146). For more information regarding the Privacy Act, you can consult Info Source at www.infosource.gc.ca.

Return of the Medical Report

Service Canada will assist with the cost of completing the medical report by paying up to $85.00 directly to you. To ensure payment, provide the completed report and your invoice to the Social Worker or Health care Professional assisting your patient in the completion of this application designed for terminally ill clients.

If your fees are higher than these amounts, please bill your patient directly for the difference.

In the case where your patient has directly requested for you to complete the terminal illness medical report, you may return the completed report and invoice to your patient or send directly to Service Canada. If you decide to mail the report directly to one of our offices, please advise your patient.

If you are requesting payment of the GST / HST please ensure to include your GST / HST number. Service Canada will endeavor to pay you as soon as possible.

If you have any questions, please contact Service Canada at 1-800-277-9914, TTY users 1-800-255-4786.

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Service Canada



PLEASE TYPE OR PRINT CLEARLY using blue or black ink.

Section E - To be completed by the Physician or Nurse Practitioner

Your patient is applying for a Canada Pension Plan disability benefit. This specific application form is to be used for those individuals who have a terminal illness. To assist us in determining eligibility, please complete this form. Include documentation to support the diagnosis / prognosis.

Patient's given name Middle name and initial Family name

Date of birth (YYYY-MM-DD)

Social Insurance Number

1. I last examined the above mentioned patient, on and certify that the following listed diagnosis(es) exist(s): (YYYY-MM-DD)

2. On what date did the patient's symptoms begin?(YYYY-MM)

3. Prognosis (select one)

Good Guarded Palliative Unknown Other:

4. When did you start treating the patient for the main medical condition?(YYYY-MM)

5. List treatment (both pharmacological and non-pharmacological)

6. If you have indicated that the prognosis is good, do you anticipate the patient returning to work within the next 12 months?

Signature of the physician or nurse practitionerIn signing this form, you are declaring that to the best of your knowledge that the information contained in this application is true and represents a complete and accurate description of the applicant's medical status.

Signature Date (YYYY-MM-DD)

Full name Specialty Telephone number

Office stamp / office address FOR OFFICE USE ONLY

A.C. Initials YYYY-MM-DD

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form isp 2530 - service canada forms · service canada protected b (once completed) terminal...

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