Gouvernement du Québec Ministère de la Santé et des Services sociaux “SHORT TEST FOR NEEDS AND RESOURCES” Form No.: Year Sequence No.
1.1 Shelter Name Address (No., street, municipality, province, postal code) 1.2 User Full name Date of birth
2.1 Are you receiving last resort financial assistance under the Individual and Family Assistance Act ? If yes , indicate your File No. and answer Question 3. If no , answer Questions 2.2 and following. 2.2 Declaration: liquid assets and income Available liquid personal assets $ (A) Available monthly personal income $ (B) Social insurance benefits from federal sources, excluding family allowances, included in (A) $ Nature of benefits
Number of children accompanying you who will also be lodged
Y M D Date User’s signature
Date of admission Date of departure Y M D Y M D Adult: Adult: Child: Child: Days present - adult Days present - child