Form Sc Isp-1151 - Application For Disability Benefits Page 5
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Social Insurance Number
DECLARATION AND SIGNATURE
PART 3 - TO BE COMPLETED BY A WITNESS IF THE APPLICANT SIGNS WITH A MARK "X"
I have read the contents of this application to the applicant, who appeared to fully understand them and who made
his/her mark in my presence.
Signature of Witness
Name of witness (Print)
Date
(YYYY-MM-DD)
X
Address (No., Street, Apt., or R.R.)
City
Province or Territory
Country other than Canada
Postal Code
Telephone number
PART 4 - TO BE COMPLETED ONLY BY A REPRESENTATIVE OF THE APPLICANT
I hereby apply for a disability and, if applicable, a child benefit under the Canada Pension Plan on behalf of the applicant
and declare that to the best of my knowledge and belief, all of the information herein is true and complete.
I agree to notify the Canada Pension Plan of any changes that may affect the applicant's eligibility for benefits.
This includes: an improvement in the medical condition; a return to work (full, part-time, volunteer, or trial
period); attendance at school or university; trade or technical training; or any rehabilitation.
I also agree to notify the Canada Pension Plan if and when I cease acting as the representative of the applicant
and/or of any changes in the applicant's condition whereby the applicant is able to act on his/her own behalf.
NOTE: A false or misleading statement may result in an administrative monetary penalty and interest, if any, under the
Canada Pension Plan, or in the prosecution of an offence. Any benefits received or obtained to which there was
no entitlement would have to be repaid.
Signature of Representative
Name of Representative (Print)
Relationship to the applicant
Date
(YYYY-MM-DD)
X
Address (No., Street, Apt., or R.R.)
City
Province or Territory
Country other than Canada
Postal Code
Telephone number
SC ISP-1151 (2015-02-23) E
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Parent category: Legal