Service
PROTECTED B (when completed)
Canada
Please read the guide before
completing the application
APPLICATION FOR DISABILITY BENEFITS
CANADA PENSION PLAN
Date Stamp
FOR OFFICE USE ONLY
Application taken by
Year
Month
Day
INFORMATION ABOUT YOU
1.
Language
Social Insurance Number
Mr.
Mrs.
Miss
Ms.
Preference
First Name and Initial
Last Name
English
French
Date of Birth
FOR OFFICE USE ONLY
Surviving spouse or
Single
Separated
Male
common-law partner
YYYY-MM-DD
Female
Married
Common-Law
Divorced
2. Home address (No., Street, Apt., R.R.)
City
Province or Territory
Country other than Canada
Postal Code
Telephone number
Mailing address if different from home address (No., Street, Apt., P.O. Box, R.R.) City
Province or Territory
Country other than Canada
Postal Code
3. If you now live outside of Canada, in which Canadian city and province or territory did you
In which year did you
leave Canada?
last reside?
City:
Province or Territory:
4. Payment Information
Direct deposit in Canada:
Complete the boxes below with your banking information.
Branch Number
Institution Number
Account Number
(5 digits)
(3 digits)
(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 613-990-2244
from all other countries (collect calls accepted). The form and a list of countries where direct deposit service is
available can be found at
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada.
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Disponible en français