Form Hr2181a - Fax Cover Sheet printable pdf download

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FAX COVER SHEET

Confidential: This facsimile is intended for the recipient named below and may contain confidential information.

If you are not the intended recipient, please contact the sender immediately and destroy all copies of this document.

Any unauthorized disclosure, distribution or reproduction of the information in this document is prohibited.

To:

Fax #:

Phone #:

Date

Priority:

Urgent

Standard

# of pages (including cover sheet):

Content:

Confidential

From:

Prevention and Loss Management Services Branch

Address:

Fax #:

Phone #:

I am requesting confirmation of earnings for the person named on the attached Confirmation of Earnings form.

This information is requested under the authority of Section 10 of the Employment and Assistance Act or Section 10 of the

Employment and Assistance for Persons with Disabilities Act.

A consent to release this information is

Please complete the attached form and return it by fax or by mail to the number or address shown above, using a separate form

for each year.

Note: the requested information is for net earnings after standard payroll deductions for income tax, employment insurance,

medical insurance, Canada Pension Plan, superannuation, company pension plan and union dues.

Any other deductions, such as for meal allowances, advances or other discretionary amounts, should be included in net earnings.

I would appreciate it if you would treat this matter confidentially.

Thank you for your assistance. If you have any questions, please contact me at the phone number above.

Sincerely,

Employment and Assistance Act/Employment and Assistance for Persons with Disabilities Act: Section 10

(1) For the purposes of ... (a) determining whether a person wanting to apply for income assistance/disability assistance or hardship assistance

is eligible to apply for it, (b) determining or auditing eligibility for income assistance/disability assistance, hardship assistance or a supplement,

... the minister may do one or more of the following: ... (f) seek verification of any information supplied to the minister by a person referred to in

paragraph (a), an applicant or a recipient.

HR2181A (14/02/21)

Form Hr2181a - Fax Cover Sheet

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