Fsd 18 Special Family Separation Assistance Application Form
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2FSD 18 Special Family Separation Assistance Application Form
Employee’s Name: ____________________________________
Mission : _________________________
□ Yes □ No
Is this your initial request for this assignment?
Date: ___________________________
Spouse □ Common-law partner □
Name: ______________________________________________
Dependant child(ren)/student(s) Name(s):
Attending school?
School Location:
___________________________________
Y/N
___ Canada* ___ Mission
___________________________________
Y/N
___ Canada* ___ Mission
___________________________________
Y/N
___ Canada* ___ Mission
___________________________________
Y/N
___ Canada* ___ Mission
* Indicate if assistance is provided under FSD 33
Date since assistance commenced: __________________________________________
Reason for Family Separation:
FSD 18.03 (a)
Unaccompanied Assignment
_____
FSD 18.03(b)
Employment of Spouse*
_____
Education of Spouse*
_____
Family Related**
_____
FSD18.03(c) or (d)
Disruption of child’s education**
_____
FSD18.03(e)
Illness of a dependant*
_____
FSD18.03(f)
Disposal of principal residence*
_____
* Please provide documentation to support the reason for family separation
Employment of spouse: e.g. letter from employer
Education of spouse: acceptance letter
Disposal of principal residence: proof of active and realistic attempts of disposal of principal residence
Illness of dependant: medical certificate
** Please attach an explanation with details supporting the reason for family separation
Have you ever been granted “separation assistance” in the past under FSD 15.34, FSD 17.04 and/or FSD
17.05? □ Yes □ No
If yes, provide dates: From
YYYY/MM/DD
To
YYYY/MM/DD
Dates of current assignment: From
YYYY/MM/DD
To
YYYY/MM/DD
Date(s) that spouse/common-law partner will not be
residing at mission: From
YYYY/MM/DD
To
YYYY/MM/DD
Will the spouse/common-law partner relocate to/from Mission during assignment? Yes or No
If yes, specify approximate dates of relocation: From
YYYY/MM/DD
To
YYYY/MM/DD
The Spouse/Common-law partner will remain in:
□
Principal residence in headquarters city
□
Other residence in headquarters city *
□
Not in headquarters city
Address: ____________________________________________________________________________
* Proof of cost of maintaining second residence (attach copy of legal documentation such as lease agreement or
mortgage statement to demonstrate expenses incurred)
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