Forms and Letters

Last updated on September 22, 2023

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.
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	Facility/Residence Invoice - Daily User Rates
HR0150B	Facility/Residence Invoice - Monthly User Rates
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.
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.
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.
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.
HR2883	Persons with Disabilities Designation Application Sample form for determining eligibility for the Persons with Disabilities designation.
HR2892	Persons with Persistent Multiple Barriers Application Form
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 Health Assistance.
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.
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.
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
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].
HR3189A	Consent to Disclosure of Information – Service Authorization
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.
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.
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.
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
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.
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.
HR3266	Client Identification Process
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.
HR3317B	MSO Eligibility - PPMB Clients Letter
HR3319	Facility/Residence Admittance, Discharge or Transfer
HR3320	Request for Local or 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 .
HR3489	CPP – 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	WorkBC ES Referral from Combined EP Letter Template letter to advise client of shift from ATI or SIWS to WorkBC ES portion of Dual EP, and requirement to attend WorkBC ES following initial six month period.
HR3549	WorkBC ES Self-Referral from Combined EP Letter Template letter to advise client of shift from ATI or SIWS to WorkBC ES portion of Dual EP, following WorkBC ES 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
HR3639	Confirmation of Income
HR3642	Persons with Disabilities Designation Application – Prescribed Class This is an application for the Persons with Disabilities Designation for member of a prescribed class. This is NOT the application for financial assistance.
HR3644	AEE Exhausted to MSO Letter
HR3677	Schedule A – Appendix A1 TPA of Benefits Services Referral Form
HR3678	Third Party Administration Client Review Form
HR3678B	Third Party Administration Client Input Form
HR3680	BC Hydro Payment Notification Letter
HR3727	Breathing Device Request and Justification
HR4003	Food and Sundries Voucher – Sample

Did you find what you were looking for?

The B.C. Public Service acknowledges the territories of First Nations around B.C. and is grateful to carry out our work on these lands. We acknowledge the rights, interests, priorities, and concerns of all Indigenous Peoples - First Nations, Métis, and Inuit - respecting and acknowledging their distinct cultures, histories, rights, laws, and governments.

More topics

Forms and Letters