Fillable Monthly Business Income And Expense Report (Page 3 of 3) in pdf

I state that the information given in this Monthly Business Income and Expense Report, is true, correct and that I

have not withheld any information which may have an effect on my social assistance benefits. I understand I may

be liable to criminal prosecution for withholding information or providing false or misleading information.

My Rights and Responsibilities

I have the right to the protection of my personal information pursuant to The Freedom of Information and Protection of

Privacy Act and The Health Information Protection Act. I have the right to access my personal information in the possession or

control of the ministry.

I understand that the information provided in this application will be retained and disposed of in accordance with The

Archives Act of the Province of Saskatchewan.

I am aware that I may appeal the assessment of my eligibility or the calculation of my benefits.

I agree to report to the Ministry of Social Services any changes in my circumstances, or the circumstances of my family

members, that effect my eligibility for assistance or the eligibility of my family members. I understand some examples of

such changes include changes include changes in address, receipt or expected receipt of money, goods or other assets from

any source, needs, number of family members, and marital status including common-law relationships. If I am in doubt as to

whether any change in circumstances will affect my eligibility, I agree to report this to the Ministry of Social Services.

I, as applicant, understand that any payments I receive for which I am not entitled, will be deducted from future payments.

I understand that excess payments result from a failure to report changes. I understand I am also responsible for re-paying

excess payments which result from my spouse’s failure to report changes.

I must make every effort to be self supporting. I understand this includes pursuing employment and child support,

participating in training or attending educational programs or obtaining income from other sources.

Client Consent

I give consent to the Ministry of Social Services to obtain and verify information or documents required to confirm my

eligibility, or the eligibility of family members for social assistance. I understand such information includes needs, money

received from any source, assets, marital status (including common-law relationships), and living arrangements of myself or

family members.

I give consent to any person having such information or documents to release them upon written or verbal request to

employees of the Ministry of Social Services. I understand examples include, but are not restricted to, information or

documents from: Human Resources and Skills Development Canada (Employment Insurance), Workers’ Compensation

Board, Saskatchewan Government Insurance, any bank, credit union or other financial institution, any landlord, and past

employers. I give consent to use my Social Insurance Number and the Health Services Number of myself and my family

members for purposes of determining our eligibility or benefits.

I give consent to the Ministry of Social Services to disclose my/our information to third parties where the information is

necessary to verify and confirm my eligibility for benefits or to assist in providing additional benefits. I understand third

party examples include, but are not restricted to, Canada Revenue agency, The Ministry of Education, the Ministry of

Economy, Workers’ Compensation Board, Canada Pension Plan, Sask Power, Sask Energy, Indian Bands, Public Trustee and

other provincial social assistance programs. I give consent to disclose and use my information for evaluation and research to

improve programs and services.

I authorize Canada Revenue Agency to release to the Ministry of Social Services any information from my income tax returns

and other taxpayer information. The information will be relevant to, and will be used solely for the purpose of determining

and verifying eligibility for, and the general administration and enforcement of the social assistance program under

The Saskatchewan Assistance Act. This authorization is valid for the taxation year prior to the year of signature and each

subsequent consecutive taxation year for which benefits are requested.

________________________________________________

_________________________________________________

Signature of Client

Signature of Spouse (if present)

________________________________________________

_________________________________________________

Signature of Trustee/Receiver

Witness (if signed by mark)

_____________________________________

Year/Month/Day

saskatchewan.ca

| Page 3 of 3 | 1214 Rev. 12/12

Monthly Business Income And Expense Report Page 3

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