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Canada / Philippines Agreement

Applying for a Philippine Retirement and/or Disability Pension

Here is some important information you need to consider when completing your application. Please ensure you sign the application. If you are signing with a mark, (for example: “X”) the signature of a witness is required. Your application must be supported by documentation. Please submit the documents requested. Failure to complete the application and provide the requested documentation may result in delays in processing your application. Where original documents are specifically requested, originals must be submitted with your application. You should keep a certified true copy of any originals you send us for your records. Some countries require original documentation which will not be returned to you. You may submit the original or a photocopy that is certified as true for any of the documents where originals are not required. It is better to send certified copies of documents rather than originals. If you choose to send original documents, send them by registered mail. We will return the original documents to you. We can only accept a photocopy of an original document if it is legible and if it is a certified true copy of the original. Our staff at any Service Canada centre will photocopy your documents and certify them free of charge. If you cannot visit a Service Canada Centre, you can ask one of the following people to certify your photocopy: Accountant; Chief of First Nations Band; Employee of a Service Canada Centre acting in an official capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Pharmacist, Psychologist, Nurse Practitioner, Registered Nurse; Member of Parliament or their staff; Member of Provincial Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government department or provincial government department, or one of its agencies; Official of an Embassy, Consulate or High Commission; Officials of a country with which Canada has a reciprocal social security agreement; Police Officer; Postmaster; Professional Engineer; Social Worker; Teacher. People who certify photocopies must compare the original document to the photocopy, state their official position or title, sign and print their name, give their telephone number and indicate the date they certified the document. They must also write the following statement on the photocopy: This photocopy is a true copy of the original document which has not been altered in any way. If a document has information on both sides, both sides must be copied and certified. You cannot certify photocopies of your own documents, and you cannot ask a relative to do it for you. Return your completed application, forms and supporting documents to: International Operations Service Canada P.O. Box 2710 Station Main Edmonton, AB T5J 2G4 CANADA

Disclaimer:

This application form has been developed by external sources in cooperation with Employment and Social Development Canada. The content and language contained in the form respond to the legislative needs of those external sources.

CAN-PHI 1

NOTE:

PLEASE PRINT/ VEUILLEZ ÉCRIRE EN MAJUSCULES

PART A. GENERAL INFORMATION ABOUT THE CONTRIBUTORPARTIE A. RENSEIGNEMENTS GÉNÉRAUX SUR LE COTISANT

1. 2. a) Social Insurance Number in Canada Numéro d'assurance sociale au Canada

First name, Middle Initial, and Last NamePrénom, initiales et nom de famille

3. Date of birth

b) Social Security Number in the PhilippinesNuméro de sécurité sociale aux Philippines

Lieu de naissance c) Government Service Insurance System Number in the Philippines/ Numéro du Système d'assurance du service du gouvernement

City or Town Province, State or Territory Country

5. Address POSTAL CODE

Adresse CODE POSTAL

6. Civil Status Married Widowed Seperated since État civil Marié (e) Veuf (veuve) Séparé (e) depuis Divorcé (e) depuis

7. Is the contributor receiving or has he (she) ever received or applied for benefits under the RP SOCIAL SECURITY LAW and/or the Government Service Insurance System (GSIS)?Le cotisant reçoit-il ou a-t-il reçu ou demandé des prestations en vertu de la LOI SUR LA SÉCURITÉ SOCIALE DES PHILIPPINES et/ou du Système d'assurance du service du gouvernement (SASG)?

SSS no/ non

GSIS/ SASG

If "yes", what type of benefit? (retirement, total/partial disability?)Si "oui", genre de prestation? (retraite, invalidité totale/partielle?)

8. Has the contributor ever paid contributions to a social security plan in a country other than the Philippines?/ Le cotisant a-t-il participé à un régime de sécurité sociale dans un pays autre que les Philippines?

If "yes", in what country or countries?/Si "oui", dans quel(s) pays?

9. Qualified dependent children/ Enfants à charge admissibles

Indicate the first and last names, and date of birth of each legitimate, legitimated, or legally adopted child who is unmarried, not gainfullyemployed, and not over 21 years of age, or over 21 years of age, provided that he is congenitally incapacitated and incapable of self-supportphysically or mentally, but not exceeding five, beginning with the youngest and without substitutioInscrivez le prénom, le nom de familleet la date de naissance de chaque enfant légitime, légitimé ou adopté légalement, célibataire, ne travaillant pas et de moins de 21 ans ou de 21 ans et plus, atteint d'une invalidité congénitale ou incapable physiquement ou mentalement de subvenir à ses besoins, sans dépassercinq enfants, en commençant par le plus jeune et sans substitution.

année

year month day Date de naissance

année mois année mois

mois jour

4. Place of birth

Ville ou Village Province, État ou Territoire Pays

Divorced since Single Célibitaire

year month year month

MonthMois

YearAnnée

Date of BirthDate de naissance

DayJour

Nom de familleLast NameFirst Name

Prénom Adresse

APPLICATION FOR RP SOCIAL SECURITY BENEFITSUNDER THE PHILIPPINES-CANADA SOCIAL SECURITY AGREEMENT

EN VERTU DE L'ACCORD PHILIPPINES-CANADA EN MATIÈRE DE SÉCURITÉ SOCIALE

Address

yes/ oui

yes/ oui

DEMANDE DE PRESTATIONS DE SÉCURITÉ SOCIALE DES PHILIPPINES

This application must be completed by the contributor or, in the case of an application for survivor's or death benefit, by the parclaiming entitlement to benefits. The term "contributor" means the person who has made contributions to the RP Social Security schemesCette demande doit être remplie par le cotisant ou dans le cas d'une demande de prestations de survivants ou de décès, par l'ayantdroit qui réclame les prestations. Le terme "cotisant" désigne la personne qui a versé des cotisations aux régimes de sécurité socialedes Philippines.

no/ non

10. Employment History/ Historique d'emploi

Employer Period of Employment Address Employeur Période d'emploi Adresse

From/ Du To/ Au

If there is not enough space, please add a separate sheet giving the required information. Si l'espace est insuffisant, veuillez donner les renseignements demandés sur une autre feuille.

PART B. APPLICATION FOR A RETIREMENT PENSION (Be sure you have completed PART A). You must be at least 60 yearsold and separated from employment.

PARTIE B. DEMANDE DE RETRAITE (la PARTIE A doit avoir été remplie). Vous devez être âgé d'au moins 60 ans et avoir cesséde travailler.

If you are between 60 and 65 years of age, have you stopped working Si vous avez entre 60 et 65 ans, avez-vous cessé de travailler?

Yes, I have stopped working on/Oui, j'ai cessé de travailler le:

year monthannée mois

No, I am still working./ Non, je travaille encore

No, I will stop working on/Non, je cesserai le:

year monthannée mois

PART C. APPLICATION FOR THE DISABILITY AND DEPENDENT'S PENSION (Be sure you have completed PART A)PARTIE C. DEMANDE DE PENSIONS D'INVALIDITÉ ET D'ENFANT À CHARGE (la PARTIE A doit avoir été remplie)

1. Exact date on which your disability began:Date exacte du début de l'invalidité?

year month dayannée mois jour

2. Have you been previously granted disability benefits? yes/ oui Dates/ Dates : Avez-vous déjà reçu une pension d'invalidité?

no/ non

3. Have you stopped working completely?Avez-vous complètement cessé de travailler?

yes/ oui If "yes", when did you stop?/Si "oui", quand avez-vous cessé?

year month dayannée mois jour

For what reasons?/ Pour quels motifs?

no/ non If "no", are you working regularly? or occassionally?

Si "non", travaillez-vous régulièrement? ou occasionellement?

4. Information about your last job? Renseignements au sujet de votre dernier emploi

Name of last employer/ Nom du dernier employeur

Period of employment/période d'emploi from todu au

year month day year month dayannée mois jour année mois jour

What position did you hold? Describe your job/ Décrivez votre emploi Quelle était votre occupation?

Did you have to work outdoors? Why did you leave this job?/Pourquoi avez-vous quitté cet emploi? Deviez-vous travailler à l'extérieur?

yes/ oui no/ non

5. Are you in a hospital or confined in an institution? yes noÊtes-vous hospitalisé ou confiné en institution? oui nonIf "yes", give details/ Si "oui", veuillez préciser:

Name of Hospital or Institution Address Telephone numberNom de l'hôpital ou de l'institution Adresse Numéro de téléphone

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6. Who is the physician best able to provide the Social Security System and/or the Government Service Insurance System with information about your disability?Indiquez le nom du médecin le plus apte à renseigner le Système de sécurité sociale et/ou le Système d'assurance du service du gouvernement sur votre invalidité.

Physician's Name:Nom du médecin:

Physician's address: Telephone number:

Adresse du médecin: Numéro de téléphone:

7. Who are the other physician(s) you have consulted about your disability?Indiquez le nom d'autre médecins que vous avez consultés au sujet de votre invalidité.

Physician's name Address Telephone NumberApproximate

ApproximativementNom du médecin Adresse Numéro de téléphone year month

année mois

8. In what medical establishments were you treated or examined? (out-patient)Dans quels établissements avez-vous été traité ou examiné? (clinique externe)

Name of establishment Address Telephone NumberApproximate

ApproximativementNom de l'établissement Adresse Numéro de téléphone year month

année mois

Information about the person completing the application on behalf of the disabled person.Renseignements concernant la personne ayant rempli le formulaire de demande pour la personne invalide.

Mr./ M.

Mrs./ Mme. First Name Last Name Relationship to disabled person Prénom Nom de famille Lien de parenté avec la personne invalideMiss/ Mlle.

Address: Postal Code: Telephone Number:Adresse: Code postal: Numéro de téléphone:

Please enclose a medical report with the application for disabilty pension.Veuillez joindre un rapport médical à la demande de pension d'invalidité.

PART D. APPLICATION FOR THE SURVIVING SPOUSE'S AND DEPENDENT PENSION (Be sure you have completed PART A)PARTIE D. DEMANDE DE PENSIONS DE CONJOINT SURVIVANT ET D'ENFANT À CHARGE (La PARTIE A doit avoir été remplie)

1. Information about the deceasedRenseignements sur la personne décédée

a) Date of death b) Place of deathDate de décès Lieu du décès

year month day City or Town Province, State or Territory Country année mois jour Ville ou Village Province, État ou territoire Pays

2. Information about the surviving spouseRenseignements sur le conjoint survivant

First and last names you are now usingPrénom at nom de famille utilisés actuellement

3. Your first and last names at birth the same orPrénom et nom de famille à la naissance les mêmes ou

4. Address of your permanent residence at the time of the contributor's deathAdresse de votre domicile permanent à la date du décès du cotisant

Postal Code Code postal

5. Your current address (if different from that shown in Section 4)Adresse actuelle (si différente de celle au Point 4)

Postal Code Code postal

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th

N

6. Your date of birth 7. Your place of birth / Votre lieu de naissance Votre date de naissance

year month day City or Town Province, State or Territory Country année mois jour Ville ou Village Province, État ou territoire Pays

8. Were you married to the contributor at the time of his/her death? Étiez-vous marié(e) au cotisant lors de son décès?

yes If "yes", give date and place of marriage oui Si "oui", date et lieu du mariage Place of Marriage

year month day Lieu du mariage année mois jour

no If "no", since when had you been living with the contributor? non Si "non", depuis quand cohabitez-vous avec le cotisant?

year month day année mois jour

Did any children result from your union with the contributor? yes no Un enfant est-il né de votre union avec le cotisant? oui non

9. Surviving descendants other than those enumerated under Question No. 9 of PART A. Descendants survivants autres que ceux énumérés à la question 9 de la Partie A.

Illegitimate minor Children (acknowledged natural and other illegitimate children) Enfants mineurs illégitimes (naturels reconnus ou autres enfants illégitimes)

First Name Prénom

Last Name Nom de famille

Date of birth Date de naissance

Address/ Adresse

(If minor, give name, address, and relationship of guardian.) (Si mineur, indiquez le nom, l'adresse et le lien avec le tuteur.)Year Month Day

Année Mois Jour

10. Surviving Ascendants (Do not complete if deceased is survived by legitimate minor children.) Ascendants survivants (Ne pas remplir si le défunt a des enfants mineurs légitimes.)

Parents of Deceased Parents de la personne décédée

First Name / Prénom Last Name / om de famille Address / Adresse

11. Surviving Collateral Relatives of Decedent (Do not complete if deceased is survived by ascendants or descendants.) Parents collatéraux de la personne décédée (Ne pas remplir si le défunt a des ascendants ou descendants survivants.)

Brothers and Sisters of Deceased Frères et soeurs du défunt

Name Nom


Address/ Adresse

(If minor, give name, address, and relationship of guardian.) (Si mineur, indiquez le nom, l'adresse et le lien avec le tuteur.)

Remarks (state whether full-blood or half-blood) Remarques

(indiquez frère, soeur ou demi-frère, demi-soeur)

Year Année

Month Mois

Day Jour

12. Other relatives within the 6 civil degree (Do not complete if deceased has living relatives falling under numbers 9 to 11.) Autres parents (6e degré au maximum) (Ne pas remplir si le défunt a des parents tel qu' indiqué aux points 9 à 11.)

Name Nom


Address/ Adresse

(If minor, give name, address, and relationship of guardian.) (Si mineur, indiquez le nom, l'adresse et le lien avec le tuteur.)

Exact relationship/ Lien de parenté exact

Year Année

Month Mois

Day Jour

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PART E. DECLARATION OF THE APPLICANT Declaration of witness where the applicant has signed with a cross (X) /Déclaration du témoin lorsque la personne qui fait la demande signed'une croix (X)

PARTIE E. DÉCLARATION DE LA PERSONNE QUI FAIT LA DEMANDE

I hereby apply, under the RP Social Security Law and/or GovernmentService Insurance System, for the benefits indicated above.I declare that,to the best of my knowledge,the informationprovided in this applicationistrue and complete and I undertake to notify the Social Security System(SSS) and/or Government Service Insurance System (GSIS) of anychange that might affect my entitlement to these benefits.

I have read this application to the applicant, who appears to understandthe contents and has signed with a cross (X). / J'ai lu cette demande à lapersonne qui la fait, et elle a semblé en comprende le contenu et a signéd'une croix (X).

Par la présente, je demande en vertu de la Loi sur la sécurité socialedes Philippines et/ou du Système d'assurance du service dugouvernement des Philippines, les prestations indiquées précédemment.Je déclare que, à ma connaissance, les renseignements fournis dans laprésente demande sont véridiques et complets et je m'engage à aviserle Système de sécurité sociale (SSS) et/ou le Système d'assurance duservice du gouvernement (SASG) de tout changement pouvant influersur le droit à ces prestations.

First and Last Name of Witness Prénom et nom de famille du témoin

Signature of Witness Signature du témoin

Signature:Signature : Address of Witness / Adresse du témoin

Date:Date :

year month day année mois jour

AUTHORIZATION TO TRANSMIT PERSONAL INFORMATION AND TO DIVULGE MEDICAL INFORMATION AUTORISATION DE TRANSMETTRE DES RENSEIGNEMENTS PERSONNELS ET DES RENSEIGNEMENTS DE NATURE MÉDICALE

For the purpose of this applicationmade under the legislationof the Philippines, I authorizethe InternationalAffairs and Branch ExpansionDivision (IABE) ofthe Social Security System (SSS) and the Social Insurance Group of the Government Service Insurance System (GSIS) to transmit to the liaison agencyand to the competent institution of Canada, designated in the Administrative Arrangement for the Application of the Agreement on Social Security betweenthe Government of the Philippines and the Government of Canada, any information concerning the SSS and/or GSIS decision, except for any informationwith respect to the amount of employment earnings or contributions made to the Social Security System and/or Government Service Insurance System.

For the period to process this application, I also authorize the Social Security System and/or Government Service Insurance System to transmit to thecompetent institution of Canada any information it may hold concerning my state of health.

Pour le traitement de la présente demande déposée en vertu de la législation des Philippines, j'autorise la Division des Affaires internationales et del'expansion de la direction générale (AIED) du Système de sécurité sociale (SSS) et au Groupe d'assurance sociale du Système d'assurance du servicedu gouvernement (SASG) à transmettre à l'organisme de liaison et à l'institution compétente du Canada, désignés dans l'Arrangement administratif pourl'applicationde l'Accord de sécurité sociale entre le gouvernement des Philippines et le gouvernement du Canada tout renseignements concernant unedécision prise par le SSS et/ou le SASG, à l'exception de renseignements relatifs aux montants des gains tirés d'emplois et aux cotisations versées auSystème de sécurité sociale et/ou au Système d'assurance du service du gouvernement .

En outre, j'autorise le Système de sécurité sociale et/ou le Système d'assurance du service du gouvernement, pour la période requise pour traiter cettedemande, à fournir à l'institution compétente du Canada tout renseignement qu'il détient concernant mon état de santé.

Signature: Date:Signature: Date:

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TO BE COMPLETED BY THE COMPETENT INSTITUTION OF CANADA À REMPLIR PAR L'ORGANISME COMPÉTENT DU CANADA

Date on which application was received year month day Date de réception de la demande année mois jour

Information about the contributor / Reseignements sur le cotisant

Date of birth Date of death Date of marriage Date of divorceDate de naissance Date de décès Date de mariage Date de divorce

year month day year month day year month day year month day année mois jour année mois jour année mois jour année mois jour

verified / vérifiée verified / vérifiée verified / vérifiée verified / vérifiée

Information about the surviving spouse / Renseignements sur le conjoint survivant

Date of birth / Date de naissance verified / vérifiée year month day année mois jour

Information about the qualified dependent children / Renseignements sur les enfants à charge admissibles

NAME NOM

DATE OF BIRTH DATE DE NAISSANCE

verified / vérifiée





I hereby declare that the information concerning civil status given in this form was taken from original documents provided by the applicant.

J'atteste que les données relatives à l'état civil inscrites sur la présente formule ont été tirées des documents originaux fournis par le requérant.

Full name of Department:Dénomination du service:

Signature: Date:Signature: Date:

Last name, first name and title of authorized person Nom de famille, prénom et titre de la personne autorisée

S E A LS C E A U

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Canada / Philippines Agreement

Documents and/or information required to support your application [CAN/PHI 1] for a Philippine Retirement and/or Disability Pension

Complete the attached forms:

• Canadian Residence [ISP 5013] (only if you are applying for a GSIS Retirement pension and have less than 15 years of contributions to the Canada Pension Plan, or a SSS Retirement pension and have less than 5 years of contributions to the Canada Pension Plan)

• Statement of Contributory Salary and Wages - Canada Pension Plan [ISP 2011]

completed by your employer if you are still working, or stopped working less than two years before applying for a GSIS pension (only if you are applying for a GSIS Retirement or Disability pension)

• Medical Report [ISP 2519], Questionnaire for Disability Benefits [ISP 2507], and

Authorization to Disclose Information/Consent for Medical Evaluation [ISP 2502] if you have never applied for a Canada Pension Plan Disability benefit (only if you are applying for a Philippine Disability pension)

Original or certified documents to be submitted:

• Birth certificate for you and any dependent children under age 21

• Proof of the dates of your entry(ies) to Canada and departure(s) from Canada (such as: Immigration 1000, passport, visa, ship or airline tickets etc.) (only if you are applying for a GSIS Retirement pension and have less than 15 years of contributions to the Canada Pension Plan, or an SSS Retirement pension and have less than 5 years of contributions to the Canada Pension Plan)

• Termination notice from your last employer or a letter of resignation, if you are under age 65

(only if you are applying for a SSS Retirement pension)

• For SSS applicants who wish to receive their pension via the Chinatrust All-day Access Card please complete the attached form. The bank requires at least two (2) certified photocopies of the valid identification documents (IDs) of the applicant (passport, citizen or senior card or driver's license)

IMPORTANT: If you have already submitted any of the documents required when you applied

for a Canada Pension Plan or Old Age Security benefit, you do not need to resubmit them.

(Ce formulaire est disponible en français - ISP 5013 F)Page 1 of 2

CANADIAN RESIDENCE

Canadian Social Insurance Number

Protected when completed - BPersonal Information Bank

HRDC PPU 175

Last NameFirst Name and Initial

Mr. Mrs.

Ms. Miss

Human ResourcesDevelopment Canada

Développement desressources humaines Canada

The following information is required to support your application for benefits under a social security agreement.If required, please provide additional information on a separate sheet of paper.

1. If you were born outside of Canada, please provide us with the following information:

• Date of arrival in Canada:

• Place of arrival in Canada:

2. List all the places where you have lived in Canada after the age of 18 and provide proof of all your entries anddepartures (immigration 1000, complete passport, airline tickets, etc.):

From(Year/Month/Day)

Province/TerritoryCityTo(Year/Month/Day)

3.

Departure(Year/Month/Day)

ReasonReturn(Year/Month/Day)

Destination

List all absences from Canada, which were longer than six months, during your Canadian residence listed innumber 2 above:

HRDC ISP5013 (2005-08-002) E

4.

Name Telephone Number

DECLARATION OF APPLICANTI declare that this information is true and complete.(It is an offence to make a misleading statement)

Signature:

Telephone number:

Please give us the names, addresses and telephone numbers of at least two people, not related to you by blood ormarriage, who can confirm your Canadian residence:

Date:X

( ) -

( ) -

( ) -

CityAddress

Year Month Day

Canadian Social Insurance Number

Page 2 of 2HRDC ISP5013 (2005-08-002) E

Please indicate to which Plan theabove contributions were madeIn what month and year did/will the contributorlast work and receive salary and wages?

Type of benefitapplied for

Indicate year(s) for which information required

Signature of applicant (print)

To assist me in applying for a Canada Pension Plan benefit please completeSection B below and return the completed form to me or to the IncomeSecurity Programs Client Service Centre mentioned below.

INSTRUCTIONS FOR EMPLOYER

Employee's Pension Contribution - Enter, in the appropriate area, the amountdeducted as the EMPLOYEE'S contribution to the Canada Pension Plan or theQuebec Pension Plan. Note that the employer's matching contribution is NOTto be reported on this form.

THIS SPACE RESERVED FOR CLIENT SERVICE ADDRESS STAMP



Name and address of contributor's employer1. 2.

Date

Name and address of applicant

STATEMENT OF CONTRIBUTORY SALARY AND WAGES – CANADA PENSION PLANINFORMATION FOR APPLICATION FOR CANADA PENSION PLAN BENEFITS

For the current year and the previous year you are requested to provide information on the contributor's salary and wages and contributions by the use ofthis form.

•

A separate Statement of Contributory Salary and Wages is required from each employer for whom the contributor worked during the year(s) concerned.•

If the contributor was self-employed and was required to make self-employed contributions you are required to provide information on the contributor'sself-employed earnings and contributions. Contact your Income Security Programs Client Service Centre to determine the information required.

•

Retirement Disability Survivors

A - TO BE COMPLETED BY THE APPLICANT

Social Insurance Numberof Contributor

• File applications for benefits immediately. Submit this Statement of Contributory Salary and Wages when completed.

Payroll number (If known)

B - TO BE COMPLETED BY EMPLOYER

$

Total Contributory

Earnings

$

Employee'sPension

ContributionContributory Earnings - Previous Year1.

Contributory Earnings - Current Year2.

July August September October November December$ $ $ $ $ $

January February March April May June$ $ $ $ $ $

July August September October November December$ $ $ $ $ $

January February March April May June$ $ $ $ $ $

$

Total Contributory

Earnings

$

Employee'sPension

Contribution

Month

Signature of Employer or Authorized Official

4. Year

Important: If your records indicate a Social Insurance Number which differsfrom that shown in Section A, please enter the number you are using.

5.

6.

Employer Account Number

Title Date

ISP 2011 (01-95) B

Contributory Earnings -Enter the total contributory salary and wages earned. Do not include any form of remuneration that is not considered as contributoryearnings under the terms of the Canada and Quebec Pension Plans. Forinstance:a) remuneration paid to the employee before and during the month in which

he reached the age of 18, or after the month in which he reached the ageremuneration paid to the employee while he was engaged in exceptedemployment;

b)

c) an amount relative to the residence of a clergyman.

C.P.P. NO.

3. Name of contributor (please print)

!

!

!

!

3. Canada Pension Plan Quebec Pension Plan

*

* Employer Account Number should be shown. It is the number assigned bythe Federal or the Province of Quebec Taxing Authorities for the purpose ofremitting Pension Plan Contributions.

b)a) c)

Diagnosis (es) - Diagnostic(s) :

How long have you knownthe patient?Depuis quand connaissez-vous le patient?

Telephone No. - N° de téléphone

Height - Taille

Initial - Initiale

Date of last visitDate de la dernière visite

Social Insurance NumberNuméro d'assurance sociale

Home Address (No., Street, Apt., or R.R.) Adresse du domicile (numéro, rue, app., ou route rurale)

Last Name - Nom de famille

When did you start treating the patientfor the main medical condition?Quand avez-vous commencé à traiter lepatient pour son état pathologique principal?

Relevant/significant medical history relating to the main medical condition: Antécédents médicaux pertinents/importants reliés à l'état pathologique principal :

2

City - Ville

Postal CodeCode postal

Personal Information BankHRDC PPU 140Fichier de renseignements personnelsDRHC PPU 140

Protected When Completed - BProtégé une fois rempli - B

Date of BirthDate de naissance

Y/A M D/J

1

3

Weight - PoidsY/A M D/JMY/A

4

( ) -

SECTION B To be completed by Physician - Doit être remplie par le médecinPlease provide factual objective opinions - Veuillez donner une opinion factuelle objective

First Name - Prénom

Province or TerritoryProvince ou territoire

MEDICAL REPORT - RAPPORT MÉDICAL

Please write legibly - Veuillez écrire lisiblementPage 1 of/de 4

SECTION A To be completed by Applicant - Doit être remplie par le demandeur



ISP-2519-00 Internet Version

The date(s) of admissionLa (les) date(s) d'admission

The reason(s) for admissionLa (les) raison(s) de l'admission

Is there supporting evidence for the main medical condition? Please attach supporting documentation.Y a-t-il des preuves à l'appui de l'état pathologique principal du patient? Veuillez joindre les documents à l'appui.


Over the past two years, has the patient been admitted to a hospital/institution?Au cours des deux dernières années, le patient a-t-il été admis à l'hôpital ou dans une institution?

Name of the Hospital(s)/Institution(s) - Nom de(s) l'hôpital(aux) ou de(s) l'institution (institutions)

YesOui

6B

6A

5

NoNon

NoNon

NoNon

NoNon

NoNon

YesOui

YesOui

YesOui

YesOui

Laboratory ReportsRapports de laboratoire

X-ray reportsRadiographies

OtherAutre

Documentation to be returnedDocuments devant être retournés

Consultants' opinionsOpinions de consultants


M D/JY/A

Please describe relevant physical findings and functional limitations.Veuillez décrire les observations physiques et les limitations fonctionnelles pertinentes.

If yes, please list:Dans l'affirmative, veuillez indiquer :

NoNon

YesOui

Treatment: List type and response.Traitement : Indiquez le genre et la réaction.


Are further consultations or medical investigations planned relating to the main medical condition?Prévoyez-vous effectuer d'autres consultations ou évaluations médicales en rapport avec son état pathologique principal?

Is the patient currently on medication(s) as a result of the main medical condition?Le patient prend-il présentement des médicaments en raison de son état pathologique principal?

9

8

7

If yes, please indicate dosage and frequency.Dans l'affirmative, veuillez indiquer la dose et la fréquence.

NoNon

YesOui

If yes, please specify:Dans l'affirmative, veuillez préciser :

NoNon

YesOui


Address - Adresse

Additional Information - Renseignements supplémentaires

Prognosis of the main medical condition of this patient - Pronostic au sujet de l'état pathologique principal du patient :


10

11

SIGNATURE (Please print or use a stamp - Veuillez écrire en lettres moulées ou estampiller)Physician's Full Name - Nom du médecin au complet

Postal CodeCode postal

Family PhysicianMédecin de famille

Initials - InitialesA.C. - C.V.Y/A D/JM

SpecialtySpécialité

FOR OFFICE USE ONLY - À L'USAGE EXCLUSIF DU BUREAU

Signature Telephone No. - N° de téléphoneY/A M D/J

X ( ) -


/or per day

Ce formulaire est disponible en français - ISP-2507F

c) Why did you stop working in the business?

d) Describe the business operation.

Date employment started Last day on the job

Number ofhours per day

Number of daysper week

If seasonal, explain period(s) of work. /or per year

Type of Work

If you are or were self-employed, provide the following information:

Have you ever been involved in any technical, trade, or on the job training?

SOCIAL INSURANCE NUMBER

Have you attended college or university?

EMPLOYEE

Name and full address of your present or most recent employer.

WORK HISTORY (BE SURE TO INCLUDE WORK DONE IN CANADA AND/OR OTHER COUNTRIES)

Have you stopped working completely?

e) What was your involvement with the business?

Salary per hour

b) When did you actually stop working in the business?

What was the highest grade youcompleted in school?

SELF - EMPLOYED

Personal Information BankHRDC PPU 140

Dates Type of program

EDUCATION

Year Month Day Year

QUESTIONNAIRE FOR DISABILITY BENEFITSCANADA PENSION PLAN

1 FIRST NAME AND INITIAL

2

3

Certificate obtained

If you have stopped working completely,provide the following information:

Year Month Day

4

5

6

7

ISP-2507-00E Internet Version

LAST NAME

Yes

No

Why did you stop working?

No, provide the following information:Part-time Volunteer Seasonal

If yes, indicate number of years and/or diploma/degree obtained.

a) Date business started Month Day

Full-time

If yes, provide the following details:

Yes, go to question 5.

Page 1 of 7

Yes

No

Protected When Completed - B

What kind of work did you do in your most recent job?

Month Day

Year



Do you plan to return to work or seek work in the near future?

Because of your medical condition, did you have to do a lighterjob or a different type of work?

Yes If yes, answer one of the following questions:

f) Are you involved in the business in any way at the present time?

No

c) b)

Social Insurance Number

SELF - EMPLOYED (CONTINUED)

Yes If yes, please describe.

Year Month Year Month Year Month

Year Month

The date you plan toreturn to your formeremployer/employment.

11

12

10

The date youwill start anew job.

a)

Has your physician told you when you can return to work?

The date you planto start looking forwork.

No

Yes If yes, give the date:No

Page 2 of 7

h) Will you declare yourself a self-employed person for incometax purposes this year?

g) What was the last year that an income tax returnon the operation of the business was filed in your name?

Date of dispositionIndicate what disposition has been made for the business:

sold

OTHER WORK HISTORY

Year Month Day

If no disposition has been made of the business, how does it operate now and what arrangements are you contemplating in thefuture?

No, provide the following information:

NoYes

IF THERE IS INSUFFICIENT SPACE TO LIST ALL YOUR OTHER TYPES OF WORK, USE THE SPACE AT THE END OF THIS QUESTIONNAIRE.

Work started Last day on the job

Name and full address of employer

Type of workNo

If yes, provide the following details:

Number of hoursper day

Number of hoursper week Year YearMonth Day Month Day

8 In the past two years, did you do any other work in addition to yourmain job (such as part-time farming, night or other employment)?

Yes

Have you done any other type of work in the last five years? To

Yes If yes, list the type of work and the dates.

FromYear Month Day Year Month Day

9

No

Yes, explain your present involvement.

profit sharingrented

If you had to stop other activities (such as hobbies, sports or volunteer work), please explain and give dates activities ceased.

OTHER BENEFITS

From

If you have other health-related conditions or impairments, please describe them.

No

State the illnesses or impairments that prevent you from working. If you do not know the medical names, describe in your own words.

Height

MEDICAL INFORMATION

Have you received regular EmploymentInsurance benefits in the last two years?

Left-handed

Describe how these illnesses or impairments prevent you from working.

Yes If yes, give the dates:


From

To

To

Year

Year

Year Year

Percentage ofpension awarded

15

17

19

20

21

16

18

Weight

When could you no longer work because of your medical condition?

Page 3 of 7

Year

Right-handed

Month Day

Month Day

Month DayMonth Day

Month Day

If any of your health problems are covered by Provincial workers' compensation benefits, provide details in each case.

InjuryYearClaim Number

If you are receiving any form of accident or illness/disability benefits, state the name of the insurance company.13

14

Province or Territory

State type of benefityou now receive.

Sitting/Standing (How long?)

Walking (How long and how far?)

Lifting/Carrying (How much and how far?)

Reaching

Bending (How much?)

Personal needs (Eating, washing hair, dressing, etc.)

Bowel and bladder habits

Remembering

Concentrating

Breathing

Driving a car (How long?)

Using public transportation

Seeing/Hearing

Speaking

Sleeping

Household maintenance (Cooking, cleaning, shopping and similaractivities)


Explain any difficulties/functional limitations you have with the following:22

Page 4 of 7

INFORMATION ABOUT YOUR PHYSICIANS

Postal Code

City

Address

Country (If other than Canada)

Country (If other than Canada) Postal Code

What were the reasons for your visits?

Address

Physician's Full Name

List all other physicians you have seen in the last two years (space for two physicians is provided). If there is insufficient space tolist all of your physicians, use the space at the end of this questionnaire.a) Physician's Full Name

Address

24

City

Specialty

When was your last visit?

Province or Territory Telephone Number

When did you first see this physician?Year Month Year Month

Were your visits related to your present medical condition?

When was your last visit?

Province or Territory

When did you first see this physician?Year MonthYear Month

Telephone Number

No

Yes If yes, explain the reasons for your visits.

b) Physician's Full Name

City

Specialty

Were your visits related to your present medical condition?

When was your last visit?When did you first see this physician?Year MonthYear Month

Province or Territory Postal CodeCountry (If other than Canada) Telephone Number

( ) -

If yes, explain the reasons for your visits.

Page 5 of 7

Yes


Provide the following information about the physician who will be completing your medical report.23

Specialist(Please specify)Family Physician

No

( ) -

List any medical devices you use (such as crutches, cane, artificial limb, splints, braces, wheelchair, hearing aid, heart pacemaker,ostomy apparatus).

Mailing address (No., Street, Apt., P.O. Box, R.R.)

Describe other treatment you receive (such as counselling, physiotherapy).

HOSPITALIZATION

Date discharged

Date admitted Date discharged

a) Name of hospital

City Province or Territory

Reason for admission and type of treatment

b) Name of hospital

City

Mailing address (No., Street, Apt., P.O. Box, R.R.)

Country (If other than Canada)

Date admittedName of attending physician

Name of attending physician

Postal Code


Year Month Day

Year Month Day

Year

Year Month Day

25 If you have been admitted to hospital in the last two years, please provide the following information. Space for two hospitals isprovided. If there is insufficient space to list all of the hospitals, use the space at the end of this questionnaire.

Province or Territory Country (If other than Canada) Postal Code

27

28

29

If future treatments or medical tests are planned, please explain, giving dates.

MEDICATION AND TREATMENTList any medication you now take.26

Reason for admission and type of treatment

Page 6 of 7

Name of medication Dosage How often

Month Day


VOCATIONAL REHABILITATION (SEE GUIDE ON PAGE 9)

If considered suitable, would you consent to a vocational rehabilitation assessment?

Use this space if required. Identify the number of the question the information belongs to.

Are you presently or have you ever been involved in a rehabilitation program?

I understand that it is an offence to make a false or misleading statement in an application for benefits.

I realize that my personal information is governed by the Privacy Act and it can be disclosed where authorizedunder the Canada Pension Plan.

I agree to notify the Canada Pension Plan of any changes that may affect my eligibility for benefits. This includes:an improvement in my medical condition; a return to work (full, part-time, volunteer, or trial period); attendance atschool or university; trade or technical training; or any rehabilitation.

If yes, please provide details.

If no, please explain.

DECLARATION AND SIGNATURE

30

29

Year

XSignature of Applicant or Representative Telephone Number

No

Yes

No

Yes

Page 7 of 7

( ) -

Month Day

AUTHORIZATION TO DISCLOSE INFORMATION/CONSENT FOR MEDICAL EVALUATION

• I hereby authorize any physician, medical specialist, hospital, medical or vocational agency, financial institution, employer, educationalinstitution, as well as any federal, provincial or municipal government department and agency, provincial social services and workerscompensation board or administrator of private insurance plans, to disclose information contained in their records to Human ResourcesDevelopment Canada, for the purpose of determining whether I am or continue to be disabled and whether any amount shall be paid orshall continue to be paid as a benefit under the terms of the Canada Pension Plan.

• For the purpose of providing further medical evidence for the evaluation of my disability, I agree, upon request by the Canada PensionPlan Administration, to be examined by a qualified physician or a medical consultant specialist and to submit to such diagnostic tests asthe physician or specialist may deem necessary. I also authorize the Canada Pension Plan Administration to provide any relevantmedical information relating to my disability to the examining physician or a medical consultant specialist for the purposes of suchexamination.

• Any personal information received by the Canada Pension Plan is protected under the Canada Pension Plan and the Privacy Act.I have the right to request access to this personal information and am aware that the information may be used or disclosed within theconditions imposed by the Canada Pension Plan and the Privacy Act and outlined in the Personal Information Bank HRDC PPU 140.

• I have read the above statements. I understand that this information is essential to determine that I have or continue to have a severeand prolonged mental or physical disability. In addition, this information will be used to determine the date my disability began andceased under the terms of the Canada Pension Plan. Should I choose not to consent to the disclosure of information and/or not toundergo a medical evaluation, I understand that a decision to grant or deny a disability benefit will be based upon the available evidencein my file.

ISP-2502-01-04 E Internet Version

DISPONIBLE EN FRANÇAIS - ISP 2502 F

Protected When Completed - A

Personal Information BankHRDC PPU 140

First Name and Initial

Home Address (No., Street, Apt., or R.R.)

( ) -

Last Name

Telephone NumberPostal CodeCountry (If other than Canada)Province or Territory

City


TO BE COMPLETED BY A WITNESS IF SIGNED WITH A MARK "X" OR BY A REPRESENTATIVE OF THE APPLICANT

First Name

This authorization form shall be valid for 2 years from the date of signature unless previously revoked in writing by the applicant or the representative signing this form. Any photographic or facsimile copy shall be as valid as the original.

DayMonthYear

X

Signature of Witness or Representative

Telephone Number

DayMonthYear

X

Signature of Applicant

TO BE COMPLETED BY THE APPLICANT

Last Name

( ) -

If signed by a representative, consent is made on behalf of the applicant.

