Medical Services Plan Premium Assistance Information (Page 2 of 2) in pdf

APPLICATION FOR REGULAR PREMIUM ASSISTANCE

Indicate your BC Personal Health Number (if you have one):

NET INCOME (tax year must be completed)

This information is from my income tax return for the tax year

APPLICANTS ARE

REQUIRED TO FILE AN

Enter your net income

(from your income tax return or Notice of Assessment)

INCOME TAX RETURN BY

Note: If net income is a negative number (e.g. $-2300.00), enter 0

APRIL 30TH EACH YEAR.

Enter the net income of your spouse

Note: If net income is a negative number (e.g. $-2300.00), enter 0

TOTAL NET INCOME (add lines 1 and 2)

AGE

DEDUCTIONS ALLOWED BY THE MEDICAL SERVICES PLAN (MSP)

Claim $3,000 for each person

SPOUSE - claim $3,000

who is 65 or older this year.

CHILDREN

If you are 65 or older this year, claim $3,000

Claim $3,000 for each child

included under your MSP

If your spouse is 65 or older this year, claim $3,000

coverage.

CHILDREN

x $3,000 =

DISABILITY

number of children

If you claimed a disability on

minus one half child care expenses

your income tax return for

claimed on your (or your spouse’s)

yourself, your spouse or child

income tax return (1/2 of line 214) .........

included under your MSP

coverage, claim $3,000 for

Difference =

➮

each disabled person.

If you claimed attendant or

DISABILITY

x $3,000 =

nursing home expenses in

number of disabled

place of disability, enclose

photocopies of receipts.

TOTAL DEDUCTIONS (add lines 4 to 8)

The maximum MSP deduction

for disability is $3,000 per

person.

ADJUSTED NET INCOME

is net income from your

ADJUSTED NET INCOME (subtract line 9 from line 3)

income tax return minus

above deductions allowed by

If this amount is $28,000 or less you qualify for premium assistance.

MSP.

Please read and sign. If you are married or living and cohabiting in a marriage-like relationship, your spouse must also sign. If someone

has Power of Attorney or another legal representation agreement and is signing on your behalf, please include a copy of the agreement.

DECLARATION AND CONSENT

I hereby consent to the release of information from my income tax returns, and other taxpayer information, by the Canada Revenue Agency to the

Ministry of Health and/or Health Insurance BC. The information obtained will be relevant to and used solely for the purpose of determining and verifying

my initial and ongoing entitlement to the premium assistance program under the Medicare Protection Act, and will not be disclosed to any other party.

This authorization is valid for the taxation year prior to the signature of this application, the year of the signature and for each subsequent consecutive taxation

year for which premium assistance is requested. It may be revoked by sending a written notice to Health Insurance BC.

I have resided in Canada as a Canadian citizen or holder of permanent resident status (landed immigrant) for at least the last 12 months immediately

preceding this application; I am not exempt from liability to pay income tax by reason of any other Act; and I am not the child of another beneﬁciary.

Signature of applicant

Signature of spouse

Date signed

(

)

Name of applicant (please print)

Name of spouse (please print)

Daytime telephone no.

Social Insurance Number

PAGE 2

HLTH-MSP 120 Rev. 2005/06/21