S-4.2, r. 13 - Regulation respecting the assessment of the needs of a person requesting emergency lodging as a victim of violence

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SCHEDULE I
(s. 1)
Short test for needs and resources

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
O.C. 1401-92, Sch. I.