STUDENT FINANCIAL ASSISTANCE APPLICATION FOR FULL-TIME STUDENT

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					                                                                                                                                                                                                    Income Security Programs                     OFFICE USE ONLY
                                                                                                                                                                                                     Income Security Programs
                                                                                                                                                                                                    Income Security Programs
                                                                                                                                                      APPLICATION FOR FULL-TIME                                                                   OFFICE USE ONLY
                                                                                                                                                                                                                                                 OFFICE USE ONLY

                                                                                                                                                       APPLICATION FOR FULL-TIME
                                                                                                                                                      APPLICATION FOR FULL-TIME
                                                                                                                                                  STUDENT FINANCIAL ASSISTANCE                                                              Date Received - yy/MM/DD

                                                                                                                                                   STUDENT FINANCIAL ASSISTANCE
                                                                                                                                                  STUDENT FINANCIAL ASSISTANCE                                                                Date Received - yy/MM/DD
                                                                                                                                                                                                                                            Date Received - yy/MM/DD




                                                                                                                                   YOU MUST SUBMIT AN APPLICATION EVERY YEAR
                                                                                                                                    YOU MUST SUBMIT AN APPLICATION EVERY YEAR
                                                                                                                                   YOU MUST SUBMIT AN APPLICATION EVERY YEAR
                                                                                                 Your academic year begins:                     August 16 - September 30                                 January                  All Other Months
                                                                                                 Your academic year begins:
                                                                                                  Your academic year begins:                     August 16 - September 30
                                                                                                                                                August 16 - September 30                                   January
                                                                                                                                                                                                         January                   All Other Months
                                                                                                                                                                                                                                  All Other Months
AllAll sections are mandatory - Placedash or or line through boxes that do not apply to you.




                                                                                                Your application deadline is:                                 July 15                                November 15             One Calendar Month Prior
    sections are mandatory - Place a a dash line through boxes that do not apply to you.
All sections are mandatory - Place a dash or line through boxes that do not apply to you.




                                                                                                Your application deadline is:
                                                                                                 Your application deadline is:                                  July 15
                                                                                                                                                              July 15                                 November 15
                                                                                                                                                                                                     November 15              One Calendar Month Prior
                                                                                                                                                                                                                             One Calendar Month Prior
                                                                                                    1	 STUDENT	INFORMATION
                                                                                                    1 STUDENT INFORMATION
                                                                                                Last Name                                                                             First Name

                                                                                                    Name STUDENT INFORMATION
                                                                                                Last11 STUDENT INFORMATION                                                            First Name
                                                                                                middle Name(s)                                                                        Previous Last Name(s)
                                                                                                  Last Name
                                                                                                Last Name                                                                                First Name
                                                                                                                                                                                      First Name
                                                                                                Middle Name(s)                                                                        Previous Last Name(s)
                                                                                                Permanent Address in the NWT
                                                                                                  Middle Name(s)
                                                                                                Middle Name(s)                                                                          Previous Last Name(s)
                                                                                                                                                                                      Previous Last Name(s)
                                                                                                Mailing Address
                                                                                                Current mailing Address
                                                                                                  Mailing Address
                                                                                                Mailing Address
                                                                                                Street Address
                                                                                                Community                                                                     Territory/Province                                   Postal Code
                                                                                                  Street Address
                                                                                                Street Address
                                                                                                Community                                                                  Territory/Province                                      Postal Code
                                                                                                Telephone                                                    Email Address (Please print clearly)
                                                                                                Community
                                                                                                (Home)   (
                                                                                                  Community   )                                                            Territory/Province
                                                                                                                                                                             Territory/Province                                    Postal Code
                                                                                                                                                                                                                                     Postal Code
                                                                                                Telephone                                                    Email Address
                                                                                                         (    )
                                                                                                Social Insurance Number
                                                                                                (Home)
                                                                                                  Telephone
                                                                                                Telephone
                                                                                                                                        Health Care Number
                                                                                                                                                               Email Address
                                                                                                                                                             Email Address
                                                                                                                                                                                     Place of Birth                                    Date of Birth - yy/mm/DD

                                                                                                         ((/ )) /
                                                                                                Social Insurance Number
                                                                                                  (Home)
                                                                                                (Home)                                  Health Care Number                           Place of Birth                                    Date of Birth - yy/MM/DD
                                                                                                Gender               Citizenship                                                            Current marital Status
                                                                                                           /           /
                                                                                                Social Insurance Number
                                                                                                  Social Insurance Number                 Health Care Number
                                                                                                                                        Health Care Number                             Place Birth
                                                                                                                                                                                     Place of of Birth                                   Date Birth - - yy/MM/DD
                                                                                                                                                                                                                                       Date of of Birthyy/MM/DD
                                                                                                Gender     //    ¡ //       Canadian
                                                                                                                               Citizen
                                                                                                                     Citizenship                     ¡ Permanent Resident                    Current Marital Status                       Will you be living with
                                                                                                  ¡ Female
                                                                                                Gender
                                                                                                  Gender         ¡ Other Citizen
                                                                                                                 Citizenship
                                                                                                               Citizenship
                                                                                                                      Canadian                                       ¡ Marital ¡ married ¡ Common youryoucontinous months)
                                                                                                                                                                     ¡ Single
                                                                                                                                                    ¡ Permanent Resident
                                                                                                                                                                  Current Single Status
                                                                                                                                                                    Current Marital Status
                                                                                                                                                                                                                  Law
                                                                                                                                                                                                                  Will parents while in
                                                                                                                                                                                                    (Living together Will12 be living with
                                                                                                                                                                                                                     for you be living with
                                                                                                  ¡ male
                                                                                                  ¡ Female                                                           ¡ Married                                    school?
                                                                                                                 ¡ (Explain): Citizen
                                                                                                                    ¡ Canadian Citizen
                                                                                                                      Canadian
                                                                                                                      Other                          ¡ Permanent Resident
                                                                                                                                                    ¡ Permanent Resident¡ Single
                                                                                                                                                                          Single                                  your parents while inin
                                                                                                                                                                                                                     your parents while
                                                                                                    ¡ Female
                                                                                                  ¡ Male
                                                                                                      Female                                                         ¡ Common Law
                                                                                                                                                                        ¡ Married
                                                                                                                                                                          Married                                    school?
                                                                                                                                                                                                                  school?
                                                                                                                                                                                                                     ¡ yes ¡ No
                                                                                                                    ¡ Other
                                                                                                                 ¡ (Explain):
                                                                                                                      Other                                        (Living together for 12 continuous months)
                                                                                                    ¡ Male
                                                                                                  ¡ Male
                                                                                               Have you ever claimed bankruptcy? ¡ yes ¡ No If “yes”, give date of¡ Common Law
                                                                                                                   (Explain):
                                                                                                                     (Explain):
                                                                                                                                                                     ¡Absolute Law
                                                                                                                                                                          Common Discharge - yy/mm/DD:
                                                                                                                                                                                                                       ¡ yes ¡ No
                                                                                                                                                                                                                     ¡ yes ¡ No
                                                                                                                                                                      (Living together for continuous months)
                                                                                                                                                                   (Living together for 1212 continuous months)
                                                                                               Have you ever claimed bankruptcy? ¡ yes ¡ No If “yes”, give date of Absolute Discharge - yy/MM/DD:
                                                                                               Do you presently have an outstanding Canada Student Loan and/or Provincial or Territorial Student Loan from any other
                                                                                                 Have you ever claimed bankruptcy? ¡ yes ¡ No “yes”, give date of Absolute Discharge - - yy/MM/DD
                                                                                               Have you ever claimed bankruptcy? ¡ yes ¡ No If If “yes”, give date of Absolute Discharge yy/MM/DD: :
                                                                                               Province Kin Address yes ¡ No If “yes”, from where?
                                                                                               Next ofor Territory? ¡ (not your spouse or children)                                         Outstanding amount?
                                                                                                 Next of Kin Address (not your spouse or children)
                                                                                               Next of Kin Address (not your spouse or children) First Name
                                                                                               Last Name

                                                                                               Next of Kin Address (not your spouse / common-law First Name
                                                                                               Last Name
                                                                                                 Last Name                                                     or children)
                                                                                                                                                           First Name
                                                                                               Relationship to you
                                                                                               Last Name                                                                               First Name
                                                                                                 Relationship you
                                                                                               Relationship to to you
                                                                                               Mailing Address
                                                                                               Relationship to you
                                                                                                 Mailing Address
                                                                                               Mailing Address
                                                                                               Street Address
                                                                                               mailing Address
                                                                                                 Street Address
                                                                                               Street Address
                                                                                               Community                                                                      Territory or Province/Country                        Postal Code
                                                                                               Street Address
                                                                                                 Community
                                                                                               Community                                                                        Territory Province/Country
                                                                                                                                                                              Territory or or Province/Country                       Postal Code
                                                                                                                                                                                                                                   Postal Code
                                                                                               Telephone                                                      Email Address
                                                                                               Community
                                                                                                 (Home)
                                                                                                 Telephone
                                                                                               Telephone
                                                                                                            (       )                                         Email Address
                                                                                                                                                                            Territory or Province/Country
                                                                                                                                                                Email Address
                                                                                                                                                                                                                                   Postal Code

                                                                                                   (Home)
                                                                                                 (Home)     ((      ))
                                                                                               Telephone                                                      Email Address
                                                                                                 (Home)     (       )
                                                                                               nwtsfa@gov.nt.ca                                                                                                                      www.nwtsfa.gov.nt.ca
                                                                                                 nwtsfa@gov.nt.ca
                                                                                               nwtsfa@gov.nt.ca
                                                                                                nwtsfa@gov.nt.ca
                                                                                               NWT8711/0309                                                                                                                           www.nwtsfa.gov.nt.ca
                                                                                                                                                                                                                                     www.nwtsfa.gov.nt.ca
                                                                                                                                                                                                                                     www.nwtsfa.gov.nt.ca
                                                                                                                                                                                                                                              PAGE 1 OF 6
                                                                                                NWT8711/0309
                                                                                               NWT8711/0309
                                                                                               NWT8711/0810             Student Financial Assistance                              Return To:  Student Financial Assistance                               PAGE OF
                                                                                                                                                                                                                                                        PAGE 1OF 6
                                                                                                                                                                                                                                                       PAGE 1 1OF6 6
                                                                                                                        Contact Numbers:Assistance
                                                                                                                         Student Financial Assistance
                                                                                                                        Student Financial Assistance
                                                                                                                          Student Financial                                                     Student yellowknife, NT X1A
                                                                                                                                                                                  Return To: Box 1320, FinancialAssistance 2L9
                                                                                                                                                                                   Return To: Student Financial Assistance
                                                                                                                                                                                  Return To: Student Financial Assistance
                                                                                                                          Contact Numbers:
                                                                                                                        Contact Numbers:
                                                                                                                        Phone: 1-800-661-0793 / 867-873-7190
                                                                                                                         Contact Numbers:                                                     Street1320,yellowknife,NT X1A 2L9
                                                                                                                                                                                               Box 1320, yellowknife, NT X1A 2L9
                                                                                                                                                                                                Box Address:
                                                                                                                                                                                              Box 1320, yellowknife, NT X1A 2L9
                                                                                                                        Fax: 1-800-661-0893 / 867-873-0336
                                                                                                                        Phone: 1-800-661-0793 //867-873-7190
                                                                                                                          Phone: 1-800-661-0793 867-873-7190
                                                                                                                         Phone: 1-800-661-0793 /867-873-7190                                  4501 - 50th Avenue in yellowknife
                                                                                                                                                                                                Street Address:
                                                                                                                                                                                              Street Address:
                                                                                                                                                                                               Street Address:
                                                                                                                          Fax: 1-800-661-0893 867-873-0336
                                                                                                                        Fax: 1-800-661-0893 //867-873-0336
                                                                                                                         Fax: 1-800-661-0893 /867-873-0336                                            4501 -50th Avenue inyellowknife
                                                                                                                                                                                                       4501 50th Avenue yellowknife
                                                                                                                                                                                                     4501 --50th Avenue ininyellowknife
  Check off what you are applying for
     2          TYPE OF ASSISTANCE
  ¡ Basic Grant                 ¡ Supplementary Grant or ¡ Remissible Loan
                               4501 - 50th Avenue in yellowknife                                       ¡ Repayable Loan
                                                                                                          Fax: 1-800-661-0893 / 867-873-0336
        TYPE OF ASSISTANCE
                OF ASSISTANCE
                    ASSISTANCE
    2 TYPE OF you are applying for
   2 off what
  Check TYPE
  ¡2 NWT Study Grant for Students with Permanent Disabilities - Please submit a completed Disability Assessment Form
                               Street Address:                                                            Phone: 1-800-661-0793 / 867-873-7190
                             Box 1320, yellowknife, NT X1A 2L9                                                      Contact Numbers:
  Check off what you are applying for
  Check off what you are applying for
  ¡ Basic Grant                 ¡ Supplementary Grant or ¡ Remissible Loan
  Check off what you are applying for
                             Student Financial Assistance                 Return To:                   ¡ Repayable Loan
                                                                                                                    Student Financial Assistance
PAGE 1 OF 6                                                                                                                                                      NWT8711/0309
  ¡ Basic Grant
  ¡ NWT Study Grant for Students¡ Supplementary Grant or- ¡ RemissibleaLoan
    Basic Grant
    Basic Grant                 with Permanent Disabilities ¡ Remissible completed Disability Assessment Form Loan
                               ¡ Supplementary Grant or ¡ Remissible Loan
                               ¡ Supplementary Grant or Please submit Loan                       ¡ Repayable
                                                                                                ¡ Repayable Loan
                                                                                                ¡ Repayable Loan




                                                                                                                                                                                     All sectionssections are mandatory a Place or dashthroughline through do thatthatnot not apply to you.
www.nwtsfa.gov.nt.ca                                                                                                                               nwtsfa@gov.nt.ca
                                              Application deadline for Canada Millennium Bursaries - July 15
  ¡ NWT Study Grant for Students with Permanent Disabilities Please submit a completed Disability Assessment Form
  ¡ NWT Study Grant for Students with Permanent Disabilities -- Please submit a completed Disability Assessment Form
  ¡ NWT Study Grant for Students with Permanent Disabilities - Please submit a completed Disability Assessment Form




                                                                                                                                                                                              All All sections are - mandatory--Place aadash or line through boxes that do apply to you.you.
                                                                                                                                                       )            (      (Home)
                                              Application deadline for Canada Millennium Bursaries - July 15
                                                                                                Email Address                                                            Telephone




                                                                                                                                                                                                  All sections are mandatory - Place a dash or line through boxes that do not apply to you.
                                                                                                                                                                                                  All sections are mandatory - Place a dash or through boxes not applydonot apply to you.
                                                                                                                                                                                                  are sections aremandatory Place dash or line throughboxes thatdo not apply to
    3 SPOUSE AND DEPENDANT INFORMATION




                                                                                                                                                                                                   All mandatory Place - dash a line or line boxes that boxes do to you.
                          Application deadline for Canada Millennium Bursaries July 15
                          Application deadline for Canada Millennium Bursaries -- July 15
                          Application deadline for Canada Millennium Bursaries - July 15
                       Postal Code                              Territory or Province/Country                                                                           Community

    3	 SPOUSE	AND	DEPENDANT	INFORMATION
  Provide the following information for your spouse/children                                                                                                    Street Address

  Provide
     3
  Name           the following information for your spouse/children
                SPOUSE AND DEPENDANT INFORMATION Care Number
                                                          Health                                                           Social Insurance Number          Living with me
                                                                                                                                                            during school?
                                                                                                                                                               Mailing Address
    3 SPOUSE AND information for your spouse/children
    3 SPOUSE AND DEPENDANT INFORMATION
    3 SPOUSE AND DEPENDANT INFORMATION
  Provide the following DEPENDANT INFORMATION Number
  Name                                   Health Care                                                                 Social Insurance Number         Living with me
  Date of Birth - yy/MM/DD Gender         Relationship to you?                                                                                       during school?
                                                                                                                                             ¡ yes ¡ No
                                                                                                                                                            Relationship to you
  Provide - yy/mm/DD ¡ Female ¡ Male for Spouse spouse/children
  Provide the/ following information for your spouse/children ¡ Other
  Name
  Provide the following information for your spouse/children
  Date of /
          Birth
                the following information ¡ your ¡you? Health Care Number
                            Gender         Relationship to Son ¡ Daughter
                                                                                                              Social Insurance Number ¡ yes ¡ with meyes,
                                                                                                                                             Living No If
                                                                                                                                             during school?
                                                                                                                                      how many days
  Name /
  Name
  Name
  Name                /               ¡ Female ¡ male         ¡ Spouse ¡ Son Health Care Number Other Social Insurance Number each month?with me
                                                                         First Name
                                                                                      ¡ Daughter ¡
                                                                                    Health  Care Number
                                                                                     HealthCare Number         SocialInsurance Number
                                                                                                              Social  Insurance Number       Living with me
                                                                                                                                              Living with me
                                                                                                                                             Living with me
                                                                                                                                             Living school?
                                                                                                                                                                        Last Name

  Date of Birth - yy/MM/DD           Gender                  Relationship to you? Health Care Number          Social Insurance Number        during school?
                                                                                                                                              during school?
                                                                                                                                             during school?
                                                                                                                                      Living during
  Name
                                                                                        Next of Kin Address (not your spouse or children)
                                                                               Health Care Number       Social Insurance Number              with me
                                     ¡ Female ¡ Male         ¡ Spouse to you? ¡ Daughter ¡ Other
                                                                           ¡ Son                                                             ¡ yes ¡ No
                     /
  Date of /Birth--yy/MM/DD           Gender                  Relationship to you?                                                     during school?
  Date of Birth - yy/MM/DD
  Date of
  Date of Birth - yy/MM/DD
          Birth
                   yy/MM/DD          Gender
                                     Gender
                                     Gender
                                                              Relationship to you?
                                                             Relationship to you?
                                                             Relationship
                                                                                                                                             ¡ yes ¡IfNo
                                                                                                                                             ¡¡ with me
                                                                                                                                             Living No¡No
                                                             ¡ Spouse ¡you? Health Care NumberOther Social Insurance Number ¡ yes¡yesschool?yes,
                               ¡ yes ¡ No If “yes”, give date of Absolute Discharge - yy/MM/DD:
                                     ¡ Female ¡ Male
                                                                                                                             Have you ever claimed bankruptcy?
                                                             ¡ Spouse ¡ Son ¡ Daughter ¡ Other
  Name
                                     ¡Female   ¡Male          ¡Spouse to Son ¡ Daughter ¡ Other                                                    yes     No
  Date of //         //
           Birth - yy/mm/DD              Female
                                     ¡ Female
                                      Gender    Male
                                              ¡ Male          Relationship ¡Son ¡Daughter ¡ Other
                                                                  Spouse        Son      Daughter                                            during ¡ No
                                                                                                                                                  yes
           /           /                                                                                                              how many days
  Name /
  Name
  Name
  Name
         ¡ yes ¡ No   /               ¡ Female ¡ male                                 ¡ Daughter ¡
                                                              ¡ Spouse ¡ Son Health Care Number Other Social Insurance Number each month?with me
                                (Living together for 12 continuous months)
                                                                                     Health Care Number
                                                                                    Health Care Number         Social Insurance Number
                                                                                                              Social Insurance Number        Living with me
                                                                                                                                              Living with me
                                                                                                                                             Living with me
                                                                                                                                             Living school?
                                                                                                                                         (Explain):
                                     Gender                  Relationship to you? Health Care Number          Social Insurance Number        during school?
  Date of Birth - yy/MM/DD
                                                      ¡ Common Law                                                                            during school?
                                                                                                                                             during school?
                                                                                                                                                               ¡ Male
                                                                                                                                      Living during
                                                                                                                                             with me
  Name                                                                         Health Care Number       Social Insurance Number
                                                                                                                                       ¡ Other
                                     ¡ Female ¡ Male         ¡ Spouse to you? ¡ Daughter ¡ Other
                                                      ¡ Married
                                                                           ¡ Son                                                             ¡ yes ¡ No
                     /
  Date of /Birth--yy/MM/DD
                                                                                                                                                               ¡ Female
                                                                                                                                      during school?
  school?
  Date of Birth - yy/MM/DD
  Date of                            Gender
                                     Gender
                                     Gender                  Relationship to you?
                                                              Relationship to you?
                                                             Relationship to you?
                                                                                         ¡ Permanent Resident                 ¡ Canadian Citizen
  Date of Birth - yy/MM/DD
                   yy/MM/DD          Gender
                                                      ¡ Single
                                                             Relationship
          Birth                                                                                                                              ¡¡ with me
                                                                                                                                             ¡ yes ¡IfNo
  your parents while in
  Name
  Date of //         //
  Will you be living with
           Birth - yy/mm/DD          ¡ Female
                                     ¡Female
                                         Female
                                     ¡ Female
                                      Gender  ¡ Male
                                               ¡Male
                                                Male
                                              ¡ Male         ¡ Spouse ¡you? Health Care NumberOther Social Insurance Number ¡ yes¡yesschool?yes,
                                                                                                                                             Living No¡No
                                                             ¡ Spouse ¡ Son ¡ Daughter ¡ Other
                                                              Relationship ¡Son ¡Daughter ¡ Other
                                                              ¡Spouse to Son ¡ Daughter ¡ Other
                                                                  Spouse
                                                        Current Marital Status
                                                                                Son      Daughter                                                  yes
                                                                                                                                             during ¡ No
                                                                                                                                                  yes
                                                                                                                                             Citizenship   No              Gender
           /           /                                                                                                              how many days
  Name /
  Name
  Name
  Name                /               ¡ Female ¡ male                                 ¡ Daughter ¡
                                                              ¡ Spouse ¡ Son Health Care Number Other Social Insurance Number each month?with me
                                                                                     Health Care Number
                                                                                    Health Care Number         Social Insurance Number
                                                                                                              Social Insurance Number        Living with me
                                                                                                                                               /
                                                                                                                                              Living with me
                                                                                                                                             Living with me
                                                                                                                                             Living school?
                                                                                                                                                                /
  Date of Birth - yy/MM/DD
    Date of Birth - yy/MM/DD         Gender                  Relationship to you? Health Care Number
                                                                       Place of Birth                         Social Insurance Number
                                                                                                                Health Care Number           during school?
                                                                                                                                              during school?
                                                                                                                                             during school?
                                                                                                                                                     Social Insurance Number
  Name                                                                         Health Care Number       Social Insurance Number       Living during
                                                                                                                                             with me
                                     ¡ Female ¡ Male         ¡ Spouse to you? ¡ Daughter ¡ Other
                                                                           ¡ Son                                                             ¡ yes ¡ No
                     /
  Date of /Birth--yy/MM/DD                                                                                                            during school?
                                                                                                                                                        )           (   (Home)
  Date of Birth - yy/MM/DD
  Date of                            Gender
                                     Gender
                                     Gender                  Relationship to you?
                                                              Relationship to you?
                                                             Relationship to you?
  Date of Birth - yy/MM/DD
                   yy/MM/DD          Gender                  Relationship
          Birth                                                                                                                              ¡¡ with me
                                                                                                                                             ¡ yes ¡IfNo
                                                                                                Email Address                                                           Telephone
  Name
  Date of //         //
           Birth - yy/mm/DD          ¡ Female
                                     ¡Female
                                     ¡ Female
                                      Gender  ¡ Male
                                         Female¡Male
                                                Male
                                              ¡ Male
                                                                                                                                             Living No¡No
                                                             ¡ Spouse ¡you? Health Care NumberOther Social Insurance Number ¡ yes¡yesschool?yes,
                                                             ¡ Spouse ¡ Son ¡ Daughter ¡ Other
                                                              ¡Spouse to Son ¡ Daughter ¡ Other
                                                              Relationship ¡Son ¡Daughter ¡ Other
                                                                  Spouse        Son      Daughter                                                  yes
                                                                                                                                             during ¡ No
                                                                                                                                                  yes      No
           /           /                                                                                                              how many days
  Name /
  Name
  Name                /
                       Postal Code
                                      ¡ Female ¡ male         ¡ Spouse ¡ Son Health Care Number Other Social Insurance Number each month?with me
                                                                                      ¡ Daughter ¡
                                                                           Territory/Province
                                                                                     Health Care Number        Social Insurance Number
                                                                                                              Social Insurance Number         Living with me
                                                                                                                                             Living with me
                                                                                                                                             Living
                                                                                                                                                                        Community

  Date of Birth - yy/MM/DD           Gender                  Relationship to you? Health Care Number                                          during school?
                                                                                                                                             during school?
                                                                                                                                             during school?
     4          RESIDENCY INFORMATION¡ Spouse ¡ Son ¡ Daughter ¡ Other
                        ¡ Female ¡ Male                                                                                                                      ¡ yes ¡ No
                     /
  Date of/Birth yy/MM/DD
                                                                                                                                                                Street Address
  Date of Birth --yy/MM/DD           Gender
                                     Gender                   Relationship to you?
                                                             Relationship to you?
  Date of Birth - yy/MM/DD           Gender                  Relationship to you?
                                                                                                                                                             ¡ yes ¡ No
                                                                                                                                                             ¡ yes ¡ No
            //      ¡ Female ¡ Male ¡ Spouse ¡ Son ¡ Daughter
                    ¡ Female ¡ Male since January ¡ Daughter ¡ Other
                    ¡ Female ¡ Male ¡ Spouse ¡ Son ¡ Daughter ¡ Other
  Provide your residency information ¡ Spouse ¡ Son 1, 1999 ¡ Other
       //                                                                                                                                                    ¡ yes ¡ No
                                                                                                                                                              Mailing Address
       /    /
     4      RESIDENCY INFORMATION
          From         To                                                                                             If you lived outside of the NWT but qualified as
                                 Community and Territory/Province
                                                              Previous Last Name(s)                                                                            Middle Name(s)
         yy/MM/DD                    yy/MM/DD                                                                                    ordinarily resident, explain:
    4 RESIDENCY INFORMATION
    4 RESIDENCY INFORMATION
  Provide your residency information since January 1, 1999
    4 RESIDENCY INFORMATION                                              First Name                                                                                     Last Name
      /     /        /      /
                                      since January 1, 1999
  Provide your residency information since January 1, 1999
  Provide your residency informationCommunity and Territory/Province
  Provide your residency information since January 1, 1999
       From             To                                                                                            If you lived outside of the NWT but qualified as
                                                                                                                    STUDENT INFORMATION                                     1
     yy/MM/DD       yy/MM/DD                                                                                                      ordinarily resident, explain:
      /From /
        From         / To /
                         To                                                                                               you lived outside of the NWT but qualified as
                                                                                                                       Ifyou lived outside of the NWT but qualified as
                                                                                                                      If you lived outside of the NWT but qualified as
       From             To           Community and Territory/Province
                                    Community and Territory/Province                                                  If
      yy/MM/DD       yy/MM/DD       Community and Territory/Province                                                              ordinarily resident, explain:
                                                                                                                                  ordinarily resident, explain:
      /     /
     yy/MM/DD
     yy/MM/DD        /
                    yy/MM/DD
                    yy/MM/DD/                                                                                                     ordinarily resident, explain:
      /     /        /      /
     One Calendar Month Prior                        November 15                                    July 15                          Your application deadline is:
      // //          // //
      /     /        /      /
      // //          // //
               All Other Months                         January                         August 16 - September 30                     Your academic year begins:


          //
 NWT8711/0309
                  //                  //      //                                                                                                                    PAGE 2 OF 6
                                           YOU MUST SUBMIT AN APPLICATION EVERY YEAR

          //      //             Print your name:
                                  // //
          /       /                   /       /
 NWT8711/0309                                                                                                                                                       PAGE 2 OF 6
Date Received - yy/MM/DD     STUDENT FINANCIAL ASSISTANCE
 NWT8711/0309
 NWT8711/0309
  NWT8711/0810
 NWT8711/0309                    Print your name:                                                                                                                    PAGE 2 OF 6
                                                                                                                                                                    PAGE 2 OF 6
                                                                                                                                                                    PAGE 2 OF 6
                                 APPLICATION FOR FULL-TIME
    OFFICE USE ONLY
                                 Print your name:
                                 Print your name:
                                 Print your name:
                             Income Security Programs
                                                                                                                                                                                                           Income Security Programs                         OFFICE USE ONLY


                                                                                                5         STUDENT CATEGORY         APPLICATION FOR FULL-TIME
                                                                                                                             STUDENT circle in front of ASSISTANCE
                                                                                             Indicate your student category by checking the FINANCIAL the appropriate category
                                                                                                                                                                                                                                                      Date Received - yy/MM/DD



                                                                                             ¡ Northern Indigenous Aboriginal Resident
                                                                                               Please provide:    YOU MUST Number
                                                                                                               Treaty Card Registry SUBMIT AN APPLICATION EVERY YEAR
                                                                                                                    Land Claim Beneficiary Number
                                                                                                Your academic year begins:       August 16 - September 30                                                       January                      All Other Months
                                                                                                                    and FORM F, if not already on file
All sections are mandatory - Place a dash or line through boxes that do not apply to you.
All sections are mandatory - Place a dash or line through boxes that do not apply to you.




                                                                                                                    Metis Local Number
                                                                                               Your application deadline is:               July 15                                                            November 15               One Calendar Month Prior
                                                                                                                    and FORM F, if not already on file

                                                                                                    Indicate how you would like to receive your monthly living allowance:
                                                                                                  1        STUDENT INFORMATION
                                                                                                                        ¡ Supplementary Grant                                         or    ¡      Remissible Loan
                                                                                              Last Name                                                                                      First Name

                                                                                             ¡ Northern Resident
                                                                                             Middle Name(s)                                                                                  Previous Last Name(s)

                                                                                                    Provide years of elementary and secondary schooling
                                                                                              Mailing Address

                                                                                                From                    To          Grades                                                                              If you lived outside of the NWT but qualified as
                                                                                                                                                              Community and Territory/Province
                                                                                               yy / MM
                                                                                              Street Address       yy / MM         Completed                                                                                       ordinarily resident, explain:

                                                                                                    /
                                                                                              Community                 /              to                                            Territory/Province                                       Postal Code


                                                                                                    /
                                                                                              Telephone                 /              to                            Email Address
                                                                                              (Home)      (         )
                                                                                                    /
                                                                                              Social Insurance Number   /              to       Health Care Number                           Place of Birth                                        Date of Birth - yy/MM/DD
                                                                                                               /               /
                                                                                              Gender/                   /
                                                                                                                     Citizenship   to                                                               Current Marital Status                         Will you be living with
                                                                                                                         ¡ Canadian Citizen                ¡ Permanent Resident                           ¡ Single                                 your parents while in
                                                                                                ¡ Female
                                                                                                 /                      /          to                                                                     ¡ Married                                school?
                                                                                                                         ¡ Other
                                                                                                ¡ Male                        (Explain):
                                                                                                                                                                                                          ¡ Common Law                               ¡ yes ¡ No
                                                                                                                                                                                                      (Living together for 12 continuous months)

                                                                                              Have you ever claimed bankruptcy? ¡ yes ¡ No If “yes”, give date of Absolute Discharge - yy/MM/DD:
                                                                                               6 INSTITUTION(S) AND PROGRAM(S)
                                                                                              Next order Address (not the spouse or children)
                                                                                             List, inof Kin of preference,yourprograms and institutions you will most likely attend this academic year
                                                                                              Last Name                                                                                       First Name
                                                                                            Institution                                                 Program                                                        Community/Territory/Province/Country

                                                                                              Relationship to you
                                                                                            Start Date - yy/MM/DD            End Date - yy/MM/DD        ¡ License              ¡ Certificate ¡ Diploma                 Distance Learning?      ¡ yes ¡ No
                                                                                                    /
                                                                                              Mailing Address  /                   /        /           ¡ Undergraduate ¡ Masters                    ¡ Doctorate       How many semesters?
                                                                                            Institution                                                 Program                                                        Community/Territory/Province/Country
                                                                                              Street Address


                                                                                            Start Date - yy/MM/DD
                                                                                              Community                      End Date - yy/MM/DD        ¡ License              ¡ Certificate ¡ Diploma
                                                                                                                                                                                 Territory or Province/Country         Distance Learning?      ¡ yes
                                                                                                                                                                                                                                              Postal Code¡    No
                                                                                                    /          /                   /        /           ¡ Undergraduate ¡ Masters                    ¡ Doctorate       How many semesters?
                                                                                              Telephone                                                              Email Address
                                                                                            Institution                                                 Program                                                        Community/Territory/Province/Country
                                                                                                (Home)     (        )

                                                                                            Start Date - yy/MM/DD            End Date - yy/MM/DD        ¡ License              ¡ Certificate ¡ Diploma                 Distance Learning?      ¡ yes ¡ No
                                                                                                /    /
                                                                                             nwtsfa@gov.nt.ca                      /        /           ¡ Undergraduate ¡ Masters                    ¡ Doctorate       How many semesters? www.nwtsfa.gov.nt.ca
                                                                                             NWT8711/0309                                                                                                                                                          PAGE 1 OF 6
                                                                                                                        Student Financial Assistance                                     Return To:           Student Financial Assistance
                                                                                                                        Contact Numbers:                                                                      Box 1320, yellowknife, NT X1A 2L9
                                                                                            NWT8711/0309
                                                                                            NWT8711/0810                                                                                                                                                        PAGE 3 OF 6
                                                                                                                        Phone: 1-800-661-0793 / 867-873-7190                                                  Street Address:
                                                                                                                               Print your name:
                                                                                                                        Fax: 1-800-661-0893 / 867-873-0336                                                    4501 - 50th Avenue in yellowknife
                                  4501 - 50th Avenue in yellowknife                                           Fax: 1-800-661-0893 / 867-873-0336
       7       INCOME OF STUDENT AND SPOUSE
                                  Street Address:                                                             Phone: 1-800-661-0793 / 867-873-7190
                              Box 1320, yellowknife, NT X1A 2L9                                                         Contact Numbers:
  List all types of income you and your spouse have earned during the 4 months before school and while you will be in
                              Student Financial Assistance                    Return To:                                Student Financial Assistance
  school. you must provide the net amount of all incomes listed. Net income is the amount after all deductions.
PAGE 1 OF 6                                                                                                                                                         NWT8711/0309

  If you do not know the exact amounts while you are completing this application, you can provide estimates and update
www.nwtsfa.gov.nt.ca                                                                                                                                    nwtsfa@gov.nt.ca
  your file with the correct amounts prior to commencing full-time studies.
  Do not list any benefits you may be eligible for through the NWTSFA program.
                                                                                                                                                           )           (      (Home)
                                                                                              Total - 4 Months Before
                                                                                                    Email Address                            Monthly While in School        Telephone
                                                                                                                                                 (during academic year)




                                                                                                                                                                                        All sections are mandatory - Place a dash or line through boxes that do not apply to you.
                                                                                                                                                                                        All sections are mandatory - Place a dash or line through boxes that do not apply to you.
                        Postal Code
                                                                                               you
                                                                    Territory or Province/Country
                                                                                                                    your Spouse               you                your Spouse
                                                                                                                                                                           Community

  1.         Full-time Employment Income
                                                                                                                                                                   Street Address
             Income Assistance
  2.         (Official document explaining benefits is required)                                                                                                  Mailing Address
             Employment Insurance,
  3.         Parental and Maternity Benefits                                                                                                                   Relationship to you
             Disability Pensions / Workers’ Compensation
  4.         Payments (Official document explaining benefits is required)    First Name                                                                                    Last Name

  5.         Alimony / Child Support Income                                                 Next of Kin Address (not your spouse or children)
             Training and Education Allowances
  6.                              ¡ yes ¡ No If “yes”, give date of Absolute Discharge - yy/MM/DD:                               Have you ever claimed bankruptcy?
             (Official document explaining benefits is required)
             Aboriginal Human Resource Development
  7.
                                   (Living together for 12 continuous months)
             Agreement (Official document explaining benefits is required)
           ¡ yes ¡ No                                                                                                                        (Explain):
                                                         ¡ Common Law                                                                                             ¡ Male
                                                                                                                                           ¡ Other
             Education Leave Allowances From Employer    ¡ Married
  8.
  school?                                                                                                                                                         ¡ Female
             (Official document explaining benefits is required)
  your parents while in                                  ¡ Single                            ¡ Permanent Resident                 ¡ Canadian Citizen
  Will you be living with                                   Current Marital Status
  9.         Child Care Subsidy
                                                                                                                                                 Citizenship                  Gender
                                                                                                                                                    /              /
  10.        Building Essential Skills Program (Part II, LMDA)
       Date of Birth - yy/MM/DD                                            Place of Birth                           Health Care Number                  Social Insurance Number

                                                                                                                                                           )           (   (Home)

  11.        Widow / Orphan Benefits
                                                                                                    Email Address                                                          Telephone



  12.        Retirement Pensions / Annuities
                        Postal Code                                            Territory/Province                                                                          Community


             Severance / Layoff Payout
  13.
                                                                                                                                                                   Street Address
             (Official document explaining benefits is required)

  14.        Profits from Investments / Rentals
                                                                                                                                                                 Mailing Address


             Tuition Benefits (not from NWTSFA)
  15.
                                                                   Previous Last Name(s)                                                                          Middle Name(s)
             (Official document explaining benefits is required)
             Travel Benefits (not from NWTSFA)                               First Name                                                                                    Last Name
  16.        (Official document explaining benefits is required)                                                        STUDENT INFORMATION                                    1
  17.        Scholarships (not included in assessments)

  18.        Bursaries / Fellowships
       One Calendar Month Prior                         November 15                                     July 15                          Your application deadline is:
  19.        National Child Benefit Supplement
             All Other Months                               January                         August 16 - September 30                     Your academic year begins:
  20.        Other (explain):
                                        YOU MUST SUBMIT AN APPLICATION EVERY YEAR
  21.        Other (explain):

  22.        Other (explain):
Date Received - yy/MM/DD       STUDENT FINANCIAL ASSISTANCE
 NWT8711/0309
  NWT8711/0810                                                                                                                                                         PAGE 4 OF 6
                                   APPLICATION FOR FULL-TIME
    OFFICE USE ONLY                 Print your name:
                               Income Security Programs
                                                                                                                                                                                                         Income Security Programs                         OFFICE USE ONLY

                                                                                                  8                              APPLICATION
                                                                                                         EXPENSES OF STUDENT AND SPOUSE                                  FOR FULL-TIME
                                                                                                                                      STUDENT FINANCIAL be in school. If you do not
                                                                                             Provide your total expenses for you and your dependants during the period you will ASSISTANCE know the exact                                           Date Received - yy/MM/DD
                                                                                             amounts while you are completing this application, you can provide estimates and update your file with the correct
                                                                                             amounts prior to commencing full-time studies. Place a dash or line in the boxes that do
                                                                                             not apply to you.                                                                                                                                    Amount

                                                                                             1.        Tuition and Fees                 YOU MUST SUBMIT AN APPLICATION EVERY YEAR
                                                                                                                                  (Total for your academic year)


                                                                                             2. Your academic year begins:
                                                                                                   Required Books and Supplies                         August academic year)
                                                                                                                                                   (Total for your16 - September       30                      January                     All Other Months
All sections are mandatory - Place a dash or line through boxes that do not apply to you.
All sections are mandatory - Place a dash or line through boxes that do not apply to you.




                                                                                             3. YourTransportation (NWT permanent residence to and from educational institution)
                                                                                                     application deadline is:                        July 15                                                 November 15                                    /trip
                                                                                                                                                                                                                                      One Calendar Month Prior

                                                                                             4.        Food / Personal Care            (Deduct spouse/roommate/boarder payments)                                                                                     /mos

                                                                                             5.        STUDENT (Deduct spouse/roommate/boarder payments)
                                                                                                   1 Rent / Mortgage INFORMATION                                                                                                                                     /mos
                                                                                              Last Name
                                                                                                       Utility Payments - Electricity, Water, Sewage, Heating Fuel, etc. Name
                                                                                                                                                                     First
                                                                                                                                                                                                                                                                     /mos
                                                                                             6.        (Deduct spouse/roommate/boarder payments)
                                                                                              Middle Name(s)                                                    Previous Last
                                                                                                       Medical and Dental Costs not Covered by Insurance or Government Name(s)                                                                                       /mos
                                                                                             7.
                                                                                                       (Explanation is required to claim amounts over $35/month per person, use separate sheet if necessary)
                                                                                              Mailing Address
                                                                                                       Alimony and Child Support (you pay to a former spouse)                                                                                                        /mos
                                                                                             8.        (Official document explaining support payment is required to claim this amount)
                                                                                              Street Address
                                                                                                       NWT Study Grant for Students with Permanent Disabilities                                                                                                      /mos
                                                                                             9.        (Provide necessary medical documentation and original receipts or quotes)
                                                                                              Community                                                                            Territory/Province                                       Postal Code
                                                                                             10.       Child Care Expenses             (your portion only)                                                                                                           /mos
                                                                                              Telephone                                                         Email Address
                                                                                                     School Related Fees for Dependants
                                                                                              (Home) (
                                                                                             11.                ) is required to claim, use separate sheet if necessary)                                                                                             /mos
                                                                                                     (Explanation
                                                                                              Social Insurance Number                         Health Care Number                            Place of Birth                                       Date of Birth - yy/MM/DD
                                                                                             12.       Other
                                                                                                          /     (Explain):   /                                                                                                                                       /mos
                                                                                              Gender                Citizenship                                                                   Current Marital Status                          Will you be living with
                                                                                             13.       Other    (Explain):                                                                                                                                          /mos
                                                                                                             ¡ Canadian Citizen                              ¡ Permanent Resident                       ¡ Single                                  your parents while in
                                                                                                ¡ Female                                                                                                ¡ Married                                 school?
                                                                                                             ¡
                                                                                             14.¡ Male (Explain): Other
                                                                                                  Other                                                                                                                                                             /mos
                                                                                                                  (Explain):
                                                                                                                                                                                                        ¡ Common Law                                ¡ yes ¡ No
                                                                                                                                                                                                    (Living together for 12 continuous months)
                                                                                             15. Other (Explain):                                                                                                                                                    /mos
                                                                                              Have you ever claimed bankruptcy?                     ¡ yes ¡ No If “yes”, give date of Absolute Discharge - yy/MM/DD:
                                                                                              Next of Kin Address (not your spouse or children)
                                                                                                  9       COMMENTS/NOTES
                                                                                              Last Name                                                                                     First Name


                                                                                              Relationship to you


                                                                                              Mailing Address


                                                                                              Street Address


                                                                                              Community                                                                            Territory or Province/Country                            Postal Code


                                                                                              Telephone                                                            Email Address
                                                                                                (Home)     (        )


                                                                                             nwtsfa@gov.nt.ca                                                                                                                                    www.nwtsfa.gov.nt.ca
                                                                                             NWT8711/0309                                                                                                                                                       PAGE 1 OF 6
                                                                                                                        Student Financial Assistance                                   Return To:            Student Financial Assistance
                                                                                            NWT8711/0309
                                                                                            NWT8711/0810                Contact Numbers:                                                                     Box 1320, yellowknife, NT X1A 2L9                PAGE 5 OF 6
                                                                                                                        Phone: 1-800-661-0793 / 867-873-7190                                                 Street Address:
                                                                                                                               Print your name:
                                                                                                                        Fax: 1-800-661-0893 / 867-873-0336                                                   4501 - 50th Avenue in yellowknife
     10	 APPLICANT	DECLARATION	and	CONSENT (must be signed and witnessed)
This information is being collected under the authority of the Access to Information and Protection of Privacy Act (ATIPP), Section 40.(a), (c) and (i) the Student
Financial Assistance Act and Regulations. The information will be used to determine my initial and continued eligibility for SFA and for the general administration
and enforcement of this program. The privacy provisions of ATIPP protect my information.
Personal information is defined under ATIPP, Section 2. All applicants have the right to examine and request correction of his or her records and to request a
review by the Information and Privacy Commissioner. If you have any questions about the collection of information, contact the SFA Supervisor, Department of
Education, Culture and Employment, SFA, Box 1320, yellowknife, NT, X1A 2L9, or call 1-800-661-0793 or 1-867-873-7190.

Part A - Applicant (Mandatory)
1.    I declare that:
      a.    The information given on this Student Financial Assistance (SFA) application and in documents in support of this application is true.
      b. I will immediately notify the SFA program in writing if my, my spouse’s, or my dependant’s personal information changes.
      c.    I understand that I cannot apply for, and am not entitled to receive student financial aid from any other province, territory or country for the same period
            of time that I am receiving SFA from the Northwest Territories (NT).
2.    I agree to:
      a.    Follow the terms and conditions of any loan documents that I have signed.
      b. Use any SFA benefits awarded to me towards the cost of my education and return any SFA refunds or benefits that I am not entitled to.
      c.    Provide information or documents to verify my initial and continued eligibility for SFA benefits within 20 days of request.
3.    I understand that:
      a.    The income that I receive from any source, including but not limited to Education Leave Benefits and Aboriginal Human Resource Development
            Agreements, must be reported immediately to the SFA program and that it may affect the amount of SFA benefits that I am eligible to receive.
      b. I may have to immediately return any SFA received in prior, current or future years if there were/are changes to my personal information.
      c.    If I make a false or misleading statement, I may be required to immediately repay all SFA benefits received and/or be denied future SFA benefits. I may
            also be subject to criminal prosecution.
      d.    If I have an outstanding debt with the Government of the Northwest Territories (GNWT), I may be denied SFA, or that debt may be deducted in part
            or whole, from my SFA benefits.
      e.    If I am unable to meet the GNWT’s credit worthiness requirements as defined in the Financial Administration manual, Section 907, under the authority of
            the Financial Administration Act, I may be denied SFA benefits.
      f.    my personal information, except for information collected from the Canada Revenue Agency, may be disclosed to third parties in accordance with Section
            48 of ATIPP for the following purposes: verifying eligibility to receive a benefit or service from the GNWT, for the purpose of collecting a debt owed to
            the GNWT, to maintenance enforcement for the purpose of enforcing a maintenance order.
      g.    SFA will contact other agencies to verity the information I have provided as part of determining my initial and continued eligibility for SFA benefits and to
            detect fraud. These agencies may include, but are not limited to the following: other GNWT departments, federal, territorial or municipal governments
            including driver and vehicle licensing programs, Human Resource Skills Development including Record of Employment and Employment Insurance, Parental
            and maternity Benefits, Canada Revenue Agency and Canada Citizenship and Immigration, Aboriginal agencies, housing management bodies, financial
            institutions, airline and travel agencies, landlords, educational institutions, employers and child care providers.
4.    I consent to the release of: personal information to the SFA program by those agencies listed in 3.g. above to verify any personal information provided
      to determine my initial and continued eligibility for SFA. I understand that if I consent to the release of my personal information to third parties, that this
      consent is valid until I advise the SFA Supervisor in writing that I withdraw my consent.
5.    I consent to the release, by the Canada Revenue Agency, to an official of the SFA program, of information from my income tax returns, and, if
      applicable, other required taxpayer information about me, whether supplied by me or by a third party. The information will be relevant to, and used solely for
      the purpose of determining and verifying my/our eligibility, entitlement for and general administration and enforcement of the SFA program under the Student
      Financial Assistance Act, Regulations and ATIPP, and will not be disclosed to any other person or organization without my approval.
      This authorization is valid for the SFA program for the three taxation years prior to the year of signature, and the most recently available tax information, the
      current taxation year, and each subsequent consecutive taxation year, for which assistance is requested by me or on my behalf. Further, I understand that, if
      I wish to withdraw this consent, I may do so at any time by writing to the SFA Supervisor.



 X                                                                                       X
     Applicant’s Signature (mandatory)                       Date - yy/mm/DD                 Witness’s Signature (mandatory)                           Date - yy/mm/DD

Part B - Spouse (Mandatory)
6.    As the applicant’s spouse, I consent to the release of my personal information to the SFA program by the agencies in section 3.g. above, for the purposes
      of determining the applicant’s initial and continued eligibility for SFA benefits. I understand that I may withdraw this consent as outlined above.


 X                                                                                       X
     Spouse’s Signature (mandatory)                          Date - yy/mm/DD                 Witness’s Signature (mandatory)                           Date - yy/mm/DD

Part C - Applicant (Optional)
7.    I further consent to the disclosure of my personal information, except for information collected from the Canada Revenue Agency, as described below:
      a.    Contact information to GNWT programs and departments to distribute information on employment and training opportunities and financial assistance.
      b.    Financial information to GNWT housing programs to determine eligibility for housing benefits.
      c.    Personal information to Aboriginal agencies for the purpose of verifying eligibility for their educational benefits.
      d.    Financial information to educational institutions for the purpose of verifying student funding.
      e.    Financial information to employers for the purpose of verifying eligibility for education benefits.
I understand that my refusal to consent to number 7 above will not result in any adverse decisions about rights, benefits or services currently being
provided to me by SFA. However, I may lose access to benefits, training and consideration for job opportunities listed in number 6 above.

 X                                                                                       X
     Applicant’s Signature                                   Date - yy/mm/DD                 Witness’s Signature                                       Date - yy/mm/DD

NWT8711/0810                                                                                                                                               PAGE 6 OF 6

                               Print your name:

				
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