Forms and Letters

HR0024 Declaration and Undertaking for a Client Lost or Stolen Payment
Form to be used when a client (payee) reports a lost or stolen unendorsed cheque or EFT payment not received.
HR0043 Cashed Cheque Request
Used if staff suspect that a cheque has been cashed.
HR0077 Work Search Activities Record
Form for recording work search activities and work search results.
HR0080A  Application for Assistance - Verbal Consent
HR0080B (Part 1) Application for Assistance - Consents (Part 1)
HR0080 (Part 2) Application for Assistance (Part 2)
HR0080R EA/EAPWD Review
HR0081 Monthly Report
Form for reporting changes in circumstances and monthly income for the purposes of determining eligibility for assistance.
HR0095 Release of Personal Information
This form may be used for release of information purposes, but its use should be restricted to situations where a third party requires specific information regarding type, amounts of and duration on assistance.
[For more information, see Related Links – Information Privacy and Security (FOIPPA) – Policy – Consent to Disclosure of Information]
HR0100 Employment and Assistance Request for Reconsideration
Form for clients to request a reconsideration of a ministry decision.
HR0101 Employment and Assistance Reconsideration Decision
Form for providing a decision to clients who have requested a reconsideration.
HR0150A Statement of Account – Adult Residential Resources for Daily User Charges
HR0150B Statement of Account – Adult Residential Resources for Monthly User Charges
HR2049 Request for Replacement of Supplier Lost, Stolen or Misdirected Assistance Payment
Form to be used when a service provider (payee) reports a lost or stolen unendorsed cheque or EFT payment not received.
HR2062 Declaration of Administrator of E and A or E and A for PWD
Form used to establish a third party as administrator of a client's assistance.
HR2098 Assignment – Veterans Affairs Canada
Form for assigning income received from Veterans Affairs Canada.
HR2100  Assignment – WorkSafeBC
Form for assigning income received from WorkSafeBC.
HR2138 Medical Equipment Request and Justification
Form for assessing eligibility for medical equipment.
HR2179 Overpayment Chart
Chart to be used by staff to show clients how an overpayment was calculated if the OPC is unavailable.
HR2181A Confirmation of Earnings Fax
Form used by Prevention and Loss Management Services to confirm a client's earnings.
HR2181B Confirmation of Earnings Mail
Form used by Prevention and Loss Management Services to confirm a client's earnings.
HR2528 Assignment of Benefit
Form for issuing hardship assistance under Awaiting EI Benefits.
HR2567 Request for Community Volunteer Supplement (CVS) and Eligibility Review
When this form is used for review, print the second page only.
HR2648 Direct Deposit Request
HR2663A Repayment Agreement/Acknowledgement of Debt (Repayable)
HR2664 Promise to Pay (Hardship)
This form is to be used when receiving repayable hardship assistance
HR2684  Repayment Agreement
HR2737 Promise to Repay – Benefit while Awaiting Reconsideration/Appeal Decision
Form to recover debt owed to the ministry where the client acknowledges the debt and agrees to pay at a later date.
HR2748 Assignment of Maintenance Rights
Form provided to client by EAW for assigning maintenance rights to the ministry. The client provides the signed and initialed HR2748 to the ministry legal representative at first appointment.
HR2749 Repayment Agreement Appeal Benefit
Form to recover debt owed to the ministry where the person acknowledges the debt and agrees to begin to repay the debt immediately by deduction from his or her monthly assistance cheque.
HR2751 Notice of Termination of Assignment of Maintenance Rights
Form for notifying a client that maintenance rights are terminated when the FM case is closed.
HR2752 Notice of Assignment of Maintenance Rights
Notice sent to respondents advising of assigned maintenance rights.
HR2771 Sponsorship Obligations – Applicant
Letter for informing applicants about the sponsor’s obligations.
HR2772 Sponsorship Obligations – Sponsor
Letter for informing sponsors of their sponsorship obligations and that they will be incurring a debt for any assistance issued to the applicant. 
HR2782 Promise to Pay Co-op Housing Shares
Form for recording a recipient's agreement to repay a co-op housing share purchase supplement if the recipient chooses the delayed repayment option.
HR2786 Verification of Sponsorship Request
Form for notifying the federal government when a sponsored person applies for assistance.
HR2797 Employability Screen
Form used in determining whether a recipient meets the criteria for Persons with Persistent Multiple Barriers (PPMB) and an optional tool for employment planning for all other clients.
HR2817 Funeral Services Billing
Form that service providers use to assess funeral costs.
HR2847 Application for Monthly Nutritional Supplement
Form for determining eligibility for the monthly nutritional supplement.
HR2863 Employment Plan
Form for outlining the conditions that a recipient is expected to follow in becoming employed or more employable, including the time frame.
HR2863A Client Activity Report
HR2864 Child Residency Statement
Form for determining whether an applicant or recipient has a dependent child.
HR2865 Client Employability Profile
Form for determining the nature and severity of a client's barriers to employment, and how each barrier may be addressed.
HR2883 Persons with Disabilities Designation Application
Sample form for determining eligibility for the Persons with Disabilities designation.
HR2892 Medical Report – Persons with Persistent Multiple Barriers
Form for determining if a recipient has a medical condition that restricts their employment options.
HR2892A PPMB Checklist
Form for determining if a recipient is eligible for PPMB.
HR2894 Orthoses Request and Justification
Form for orthotic and bracing suppliers to request preauthorization from HAB.
HR2916 Voluntary Participation Plan
Form for recording, for a recipient with no employment obligations, the activities intended to result in employment, increased employability, or increased self-reliance.
HR2920 Employment Plan – Second Appointment Letter
Template letter to re-book missed interview.
HR2921 Employment Plan Non-compliance Advice
Template letter to clients about non-compliance.
HR2949 For clients not receiving BC Family Bonus
Template letter to provide clients with information on the Family Bonus Top-Up Supplement.
HR2988S Simplified Monthly Self-Employment Report, (Short Form)
HR2988L SEP Client Monthly Report, (Long Form )
HR2998 SEP Acceptance of Terms and Business Plan
Completed by the EAW that provides both of the following: the client's signature agreeing to abide by the terms and conditions of the SEP as set out in BCEA legislation.
HR2999 Trust Query Form
HR3010 SEP Monthly Reporting Worksheet
Worksheet that SEP clients may use as a tool to assist them in completing the SEP Client Monthly Report (HR2988). Use of the HR3010 is optional, but recommended.
HR3028 Alcohol and Drug Fee Authorization Agreement
Form for client authorization of deductions from monthly support allowance to pay for alcohol and drug clinic fees.
HR3029 Photo Identification Card Referral
Referral form to supplier for clients to obtain photos for ID purposes.
HR3032 Cheque Hold Letter
HR3033A Family Maintenance Questionnaire and Referral
A questionnaire for the EAW to determine if the client and/or spouse is eligible for a referral for family maintenance services and this form is provided to the client to present to the ministry legal representative as proof of eligibility for services referral.
HR3034  Information/Documentation Checklist
HR3037 Shelter Information
Form to assist applicants or clients to provide the information required to determine actual shelter costs.
HR3042 Client Initiated Overpayments Letter
HR3043 Ministry Initiated Overpayments Letter
HR3069 Medical Report – Employability
Form for clients requiring a medical report to determine if the client's condition interferes with seeking, accepting or continuing employment.
HR3074 Employment Plan – Failure to Complete
Template letter to clients with consequences when failing to complete an Employment Plan.
HR3092 Overpayment Notification (For Open Case)
Form used by staff to notify clients with open cases of an overpayment and to inform them of their right to reconsideration.
HR3092A Overpayment Notification (For Closed Case or Medical Services Only Case)
Form used by staff to notify persons with closed cases or medical services only cases of an overpayment and to inform them of their right to reconsideration.
HR3103 Medical Report – Child
Form to identify a child's physical or mental condition, which precludes a recipient from working more than 30 hours a week.
HR3104 Family with a Child with Disabilities Exemption – Denial Letter
A template letter to clients, who after a review of information, have been determined to be ineligible or no longer eligible for a $500 earnings exemption.
HR3107 Assessment for Earnings Exemption – Questionnaire
Questionnaire to be used to assess how the medical needs of the child prevents the client from working more than 30 hours a week.
HR3110 Advisement that Guardian Must Sign for Release of Child's Medical Information
A letter regarding the Medical Report Child (HR3103) when the recipient/caregiver is not the parent or legal guardian.
HR3115 Reasonable Work Search Activities Guidelines
HR3116 Work Search Review
HR3125 Consent to Release Information
HR3138 Diet Supplement Review
HR3139  Diet Supplement Denial
HR3143 CPP Early Retirement Initial Contact Letter
Letter for informing clients they are required to apply for CPPE.
HR3162 Seniors Supplement – Retroactive Payments and Adjustments
HR3163 Sanctions – Inaccurate or Incomplete Reporting – PWD – Overpayment
Letter advising client of sanction for inaccurate or incomplete reporting.
HR3164 Sanctions – Inaccurate or Incomplete Reporting – Overpayment
Letter advising client of sanction for inaccurate or incomplete reporting.
HR3183 Youth Transition Consent: Youth with Intellectual Disabilities
HR3184 Child in the Home of a Relative Screening Consent
HR3187 Aboriginal Self Identifier
A form which requests clients to self identify if they are an Aboriginal person.
HR3189 Consent to Disclosure of Information
A form that gives the ministry permission to discuss a client's personal information with a third party. [For more information, see Related Links – Information Privacy and Security (FOIPPA) – Policy – Consent to Disclosure of Information].
HR3196 Request for Information
HR3197 Second Request for Information
PLMS letter to request that a recipient provide information that will assist with a compliance review (2nd request).
HR3198 Notice of Decision Section 10 Denial
PLMS letter to advise recipients of a decision to deny assistance as a result of their failure to provide information as requested. This letter also advises the recipient of their right to reconsideration or appeal.
HR3199 Notice of Decision Overpayment
PLMS form to notify clients with Open or Closed cases of an overpayment and to inform them of their right to reconsideration of this decision
HR3200 Notice of Eligibility Decision
PLMS letter to advise recipients of a decision affecting their eligibility and their right to reconsideration or appeal.
HR3203 Criminal Code Conviction Letter
PLMS letter advising client of sanction imposed as a result of a Criminal Code Conviction.
HR3209 Denial of CIHR Assistance (not screening), Template Letter
HR3211 Denial of CIHR Assistance (screening – discontinuation), Template Letter
HR3216 School Start-up
Confirmation of eligibility for school start-up supplement.
HR3217 Incomplete HR0081 – Monthly Report Form
Letter advising clients to complete the HR0081 in full and/or provide any required documentation.
HR3218 Bank Profile Information Sheet
Letter advising recipient to provide a copy of bank statement and bank profile.
HR3219 Information to New BCEA Client
Template letter which will advise new clients of some additional information about ministry services.
HR3220 Information to New Persons with Disabilities Designation
Letter given to new PWD designated clients advising them of additional services for which they may be eligible.
HR3221 Reconsideration Approval Cover Letter
Cover letter advising that the reconsideration decision has been approved.
HR3222 Reconsideration Denial Cover Letter
Cover letter advising that the reconsideration decision has been denied.
HR3223 Reconsideration Time Limits Exceeded Letter
Letter advising clients that the reconsideration was not submitted within the legislated 20 business day time limit.
HR3224 Income in Excess – Earned and Unearned Income
A template letter to clients who have been determined to be ineligible for income assistance for a specific duration as the family unit’s earned income was more than the amount of assistance payable to the family unit.
HR3225 Income in Excess – Family with Child with a Disability
A template letter to a Family with a Disabled Child who has been determined to be ineligible for income assistance for a specific duration as the family unit’s earned income was more than the amount of assistance payable to the family unit.
HR3227 Income in Excess – PWD Earned and Unearned Income
A template letter to clients designated as PWD who have been determined to be ineligible for assistance for a specific duration as the family unit’s earned and/or unearned income was more than the amount of assistance payable to the family unit.
HR3228 Old Age Program Benefits Letter
Template letter to clients who may be eligible for Old Age Security Program benefits.
HR3230 Sanctions – Employment Related Obligations – Non-Compliance
HR3232 First Appointment – PPMB Review
Template letter for scheduling appointments for reviewing PPMB.
HR3233 First Appointment – Other Appointment
Letter advising clients of a scheduled appointment time.
HR3235 Second Appointment – PPMB Review
Template letter to follow up if recipient missed first appointment for reviewing PPMB.
HR3236 Second Appointment – Other Appointment
Letter advising clients of a re-scheduled appointment time.
HR3237 Information Required – Medical
HR3238 Information Request – General
A template letter advising a client of documentation required to be submitted (i.e. confirmation of employment).
HR3241 PPMB Approval (Single Person)
HR3242 PPMB Approval (Single Parent)
HR3243 PPMB Approval (Both Applicant and Spouse Approved)
HR3245 PPMB Denial – New PPMB Applicant
Template letter for notifying a client who is not receiving PPMB rates that he or she is not eligible for PPMB.
HR3246 PPMB Denial – Clients currently receiving PPMB rates
Template letter for notifying a recipient who is receiving PPMB rates that he or she is no longer eligible for PPMB.
HR3247 PPMB Denial – No Contact
Denial letter for clients who failed to provide the PPMB Medical Report for the PPMB review.
HR3248 Employment Plan – First Appointment Letter
Template letter to set interview for development or review of Employment Plan.
HR3249 CPPD Information Letter When Applying for PWD
Letter for informing PWD clients they are required to apply for CPPD.
HR3251 Confirmation of ID for Financial Institution
Letter given to clients with a copy of their ID on file to assist with opening a bank account.
HR3254 Direct Deposit Template Letter
HR3258 SEP Questionnaire and Terms of Acceptance
HR3259 Assets in Excess Pending PWD Designation Application
A template letter provided with the PWD Designation Application to clients who intend to apply for PWD designation while in receipt of income assistance with assets in excess.
HR3260 Assets in Excess Pending PWD Designation Application (60 days)
A template letter to request clients to submit their completed PWD Designation Application before the specific date, if they are in receipt of income assistance with assets in excess.
HR3261 PWD Asset Exemption File Closure
A file closure template letter to clients, who have not submitted their completed PWD Designation Application and have been determined to be no longer eligible for the asset limit exemption.
HR3262 PPMB No Contact – Missed Appointment
Denial letter for clients who failed to attend a second booked appointment and did not provide a medical report.
HR3265 Notice of End of Assignment of Maintenance Rights
Notice sent to respondents advising of the end of the assigned maintenance rights.
HR3266 Client Identification Form
HR3267 Two-Year Independence Assessment
HR3271 Identity Verification Checklist
Checklist completed by person doing identity verification through the CIP process and third party checks.  This form is to be scanned and profiled.
HR3311 Statute Conviction Letter
PLMS letter advising client of consequence imposed as a result of a conviction under the EA Act or EAPWD Act.
HR3315 Notice of Change Due to Request for Reconsideration or Appeal
PLMS letter advising clients of a change to their ongoing assistance, overpayment or repayment amount as a result of their reconsideration or appeal request.
HR3317 MSO Notification
Letter regarding qualification for MSO. 
HR3319 Admittance and Discharge
HR3320 Request for Non-Local Medical Transportation Assistance
Form for assessing medical transportation supplement.
HR3322 Life-Threatening Health Need Applicant Inquiry
HR3327 Accommodation Confirmation
Letter to confirm accommodation and pay hotel direct.
HR3331 Eligibility Review for Income Assistance for CIHR
Form for determining ongoing eligibility for child in the home of a relative assistance.
HR3332 Outstanding Warrant Check Form
Form used for third party check on outstanding warrant.
HR3334 Notifying Client of Outstanding Warrants
Denial letter due to outstanding warrant and advice to seek legal help.
HR3335 Request for Client Consent to Verify Outstanding Warrant
Letter to advise client of allegation on outstanding warrant and requirement to verify.
HR3342 CPPD Package & Consent to Deduct and Payment Form – Second Letter
HR3343 CPPD Package & Consent to Deduct and Payment Form – Initial Letter
HR3344 CPPD Information Letter for Approved PWD Applicants – Initial Letter
HR3345 CPPD Information Letter for Declined PWD Applicants
HR3470 CPPD Request for Status of CPP Application Letter
Letter requesting confirmation of the results of a client's application for CPPD.
HR3472 CPP Tax Exemption Letter
Letter sent to clients when issuing a one-time tax liability adjustment cheque .
HR3485 Employment Readiness Information Questionnaire
Form for assessing employability, embedded in the Self Serve Assessment and Application (SSAA) tool.
HR3489 CPPD/E – Letter Enclosing ISP1613
Letter sent to clients that have applied for CPP and have not completed the ISP1613.
HR3500 Bus Pass Program Consent to Disclosure form
A form that gives the ministry consent to the disclosure of any personal information to a designated third party that is relevant to eligibility for the BC Bus Pass Program.
HR3508 Annual Earnings Exemption Threshold Letter
HR3510 PWD Youth Transition Information Application Letter
Letter sent to new youth PWD applicants with Intellectual Disability and/or transitioning from the Ministry of Children and Family Development At Home Program Medical Benefits.
HR3533 Third Party Administration – Advance Notice – Behavioural
Letter warning clients of potential for third party administration arrangement due to behavioural issues.
HR3534 Third Party Administration – Advance Notice – Financial Management
Letter warning clients of potential for third party administration arrangement due to financial management issues.
HR3535 Third Party Administration – Client Notification – Behavioural
Letter advising of decision to third party administer the client due to behavioural issues.
HR3537 Third Party Administration – Modifying Third Party Arrangement – Conditional
Letter advising clients that the conditions of the third party administration arrangement have been modified.
HR3538 Third Party Administration – Continuing Third Party Administration Arrangement – Behavioural
Letter advising clients that after a review, their third party administration agreement will continue due to behavioural issues.
HR3539 Third Party Administration – Removing Third Party Administration Arrangement
Letter advising clients that after a review, their third party administration arrangement has been removed.
HR3548 EPBC Referral from Combined EP Letter
Template letter to advise client of shift from ATI or SIWS to EPBC portion of Dual EP, and requirement to attend EPBC following initial six month period.
HR3549 EPBC Self-Referral from Combined EP Letter
Template letter to advise client of shift from ATI or SIWS to EPBC portion of Dual EP, following EPBC acceptance for case management within initial six month period.
HR3557 1st CRV Appt (in person)
HR3558 1st CRV Appt (telephone)
HR3559 2nd CRV Appt (in person)
HR3560 2nd CRV Appt (telephone)
HR3561 Notice of Decision – Denial for CRV Non-Attendance
HR3582 Eligibility Review Documents: First Request
Letter advising recipients to provide documents for an eligibility review
HR3583 Eligibility Review Documents: Second Request
Letter advising recipients of second request to provide documents for an eligibility review as documents were not provided following first request.
HR3584 Eligibility Review Interview: First Request
Letter advising recipient of interview time scheduled to complete an eligibility review.
HR3585 Eligibility Review Interview: Second Request
Letter advising recipient of second interview time schedules as recipient missed the first interview.
HR3586 Eligibility Review Non-Compliance Denial
Letter advising client of ineligibility for assistance due to not providing documents and/or attending an interview to complete an eligibility review.
HR3599 Instructions for Service Providers
This form gives instructions for service providers or suppliers on setting up direct deposit payments.
HR3618 THS Notification Letter
Letter regarding qualification for THS
HR3642 Persons with Disabilities Designation Application – Prescribed Class
HR3660 Request for Alternative Hearing Assistance Supplement
HR4003 Food and Sundries Voucher – Sample
IMM1000
*paper form*
Record of Landing
CIC issued identification for confirming a recipient’s identity and immigration status (issued prior to June 28, 2002). [For information on replacing immigration documents, see Contacts.]
IMM5292
*paper form*
Confirmation of Permanent Residence
CIC issued identification for confirming a recipient’s identity and immigration status when accompanied by the recipient’s Permanent Resident Card. [For information on replacing immigration documents, see Contacts.]