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.
|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)|
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.
|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
|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.
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.
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.
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.
|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.
|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.
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].
|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|
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).
|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.
|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.
Letter regarding qualification for MSO.
|HR3317B||MSO Eligibility - PPMB Clients Letter|
|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|
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||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
|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.
|HR3677||Schedule A – Appendix A1 TPA of Benefits Services Referral Form|
|HR3680||BC Hydro Payment Notification Letter|
|HR4003||Food and Sundries Voucher – Sample|
|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.]
|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.]