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SC Ins5223

This document is a form for individuals who are not family members but are considered 'like family' to apply for Employment Insurance Family Caregiver or Compassionate Care benefits. It requires patient information, a representative's details if applicable, and an attestation from the patient or their representative. The information collected is governed by the EI Act and the Privacy Act, and it may be used for policy analysis and research purposes.

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153 views1 page

SC Ins5223

This document is a form for individuals who are not family members but are considered 'like family' to apply for Employment Insurance Family Caregiver or Compassionate Care benefits. It requires patient information, a representative's details if applicable, and an attestation from the patient or their representative. The information collected is governed by the EI Act and the Privacy Act, and it may be used for policy analysis and research purposes.

Uploaded by

mdanis.mnm
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Service PROTECTED B WHEN COMPLETED

Canada
Claimant Name: SIN:

Family Member Attestation for


Employment Insurance Family Caregiver Benefits or Compassionate Care Benefits
Individuals who are not family members but are considered to be “like family” can apply for Family Caregiver benefits and
Compassionate Care benefits. This form must be completed by the non-family individual who wishes to claim Family
Caregiver benefits or Compassionate Care benefits.

If possible, the patient should sign this form. If the patient is not an adult or is unable to sign this attestation because of a
physical or mental condition, the patient’s legally authorized representative can sign the form.

PATIENT INFORMATION
Last name: Given name(s): Date of birth (yyyy-mm-dd):

HOME ADDRESS
Apartment number Street number and name City or town

Province, territory or state Postal or Zip code Country

PATIENT'S REPRESENTATIVE (if applicable)


Name of representative (please print)

Relationship to patient Phone number

ATTESTATION
I, attest that
(patient or representative name - please print) (claimant name - please print)

is considered to be like a family member for the purposes of (EI) Family Caregiver or Compassionate Care Benefits.

Patient or representative signature Date

The information provided on this form is collected under the authority of the EI Act to determine eligibility for Family
Caregiver or Compassionate Care benefits.

The information provided may also be used for policy analysis, research and/or evaluation purposes, in which case,
various sources of information under the custody and control of Employment and Social Development Canada may be
linked. In some instances, information may be disclosed without consent according to the Department of Employment
and Social Development Act (DESD Act).

The personal information collected is administered in accordance with the EI Act and the Privacy Act. Individuals have
the right to the protection of and access to their personal information. Information will be retained in the Personal
Information Bank. Instructions for obtaining this information are outlined in the government publication entitled “Info
Source,” a copy of which is located at all Service Canada Centres. Info Source is also located at the following address:
canada.ca/infosource-esdc.

SC INS5223 (2019-12-007) E Page 1 of 1

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