Form Sc Isp-1151 - Application For Disability Benefits Page 2
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6PROTECTED B (when completed)
Social Insurance Number
5. State your last name at birth (if different from Question 1).
State the last name shown on your Social Insurance Number Card (if different from
FOR OFFICE USE ONLY
Question 1).
6. Have you ever lived or worked in another country?
Yes
No
If yes, list below all of the places you have lived or worked outside of Canada and your social security identification
number(s).
Has a benefit
Residence
Employment
Social Security
been requested
Name of
or received from
Number in that
From
To
From
To
that country?
Country
Country
Year
Month
Year
Month
Year
Month
Year
Month
Yes
No
(Note: If you need more space, use a separate sheet of paper.)
If yes, indicate under
7. Have you ever applied for, or received:
Applied
Received
which Social Insurance
Number.
Yes
No
Yes
No
Canada Pension Plan
Quebec Pension Plan
Old Age Security
8. Provide your spouse's or common-law partner's full name and Social
Insurance Number, if available.
INFORMATION ABOUT YOUR CHILDREN
PROVIDE INFORMATION SINCE THE TIME YOU BECAME DISABLED UNTIL THE PRESENT.
9. Do you have any children born after December 31, 1958?
If yes, complete the provided "Canada Pension Plan Child Rearing Provision" form (ISP-1640)
Yes
No
and return it with this application.
CHILDREN UNDER AGE 18
10. Do you have children under the age of 18 in your custody and control?
No
Yes
If yes, provide the following information for each child.
First Child's First Name and Initial
Last Name
Social Insurance Number
Date of Birth
FOR OFFICE USE ONLY
Natural Child
Legally Adopted
Male
YYYY-MM-DD
Other (Explain circumstances)
Female
Second Child's First Name and Initial
Last Name
Social Insurance Number
Date of Birth
FOR OFFICE USE ONLY
Natural Child
Legally Adopted
Male
YYYY-MM-DD
Other (Explain circumstances)
Female
IF THERE IS INSUFFICIENT SPACE TO LIST ALL OF YOUR CHILDREN, USE A SEPARATE SHEET, NOTATE YOUR SOCIAL
INSURANCE NUMBER, SIGN IT AND ATTACH IT TO THIS APPLICATION.
SC ISP-1151 (2015-02-23) E
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