S-5, r. 1 - Regulation respecting the application of the Act respecting health services and social services for Cree Native persons

Schedule Disposition versions

2021-09-09

SCHEDULE V

(Revoked)

R.R.Q., 1981, c. S-5, r. 1, Sch. V; O.C. 456-82, s. 2; O.C. 1134-2021, s. 2.

2012-09-01

SCHEDULE V

(s. 353)

 Surname (in accordance with the Act of Birth if applicant is a woman)	Given name(s)	Birthdate
 Capacity		Social Insurance Number
 Address	Street	Municipality	Postal code	Telephone
 Employer				Telephone
 Address	Street	Municipality

	
APPLICATION FOR EXEMPTION FROM CONTRIBUTION FOR THE PLACEMENT OF CHILDREN
Name	
Address
Surname (in accordance with the Act of Birth if applicant is a woman)	Given name(s)	Birthdate
 Capacity		Social Insurance Number
 Address	Street	Municipality	Postal code	Telephone
 Employer		Address	Municipality	Telephone
	Name	Given name(s)	Birthdate	Relationship	Occupation	Income
Surname	Given name(s)	Birthdate
Reasons for placement
Surname	Given name(s)	Birthdate
Reasons for placement
Surname	Given name(s)	Birthdate
Reasons for placement
Raison du placement

TAXABLE ANNUAL INCOME		
Source	1st parent	2nd parent
1.   Salary before deductions, salary insurance, commissions tips, gratuities, other earned income		
2.   Old-age security pension and supplement		
3.   Quebec Pension Plan or Canada Pension Plan benefits		
4.   Other pension benefits
Specify
	
			
5.   Unemployment insurance benefits		
6.   Alimentary pension received		
7.   Adult professional training allowance		
8.   Income from business enterprise
Specify
	
			
9.   Dividends and other income		
10. Total taxable earnings		
11. Grand total taxable earnings		
		
NON TAXABLE INCOME		
12. Social aid allowances		
13. Family allowances		
14.  CSST benefits		
15. Supplements
Specify
	
			
16. Other non taxable income		
17. Total non taxable income		
18. Grand total non taxable income		
		
19.  Grand total taxable and non taxable income (items 11 and 18)		
		
20. Enter social aid file number if applicable		


DEDUCTIONS		
Deductions	1st parent	2nd parent
21. Contribution to a pension plan	
	
22. Maximum deduction of 3% for working expenses (max. 500$)		
23. Unemployment insurance benefits		
24. REEL, REER, REA benefits paid		
25. Union dues		
26. Alimentary pension paid		
27. Tuition fees		
28.  Moving expenses		
29. Other deductions
Specify
	
		

	
30. Total		
31. Grand Total		
		
32. Annual gross income (item 19  less item 31).		
		
EXEMPTIONS		
33. Adult(s)		
34. Children 0-17 years of age
			  x		=
35. Students 18 years of age and over
			  x		=		
36. Total exemptions		
		
37. Contribution income (item 32 less item 36)		

SOLEMN DECLARATION
I, the undersigned, solemnly declare that the information I have provided in this application is exact and that I have neither concealed nor omitted any pertinent information; I make this solemn declaration, knowing it to be true and to have the same force and effect as if it were made under oath.
I promise to immediately inform the social service center of any change in the situation described in this application.
I authorize the social service center and the Ministère de la Santé et des Services sociaux to question the Ministère du Revenu du Québec, the other Departments or third parties as to the accuracy of the information provided in this application.
37. Signature of father or mother	Date
38. Signature of person responsible at the contribution end	Date

R.R.Q., 1981, c. S-5, r. 1, Sch. V; O.C. 456-82, s. 2.