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DECLARATION OF INCOME

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DECLARATION OF INCOME Powered By Docstoc
					                                                                       DECLARATION OF INCOME
                                                                                    For the New Brunswick
                                                                                 Prescription Drug Program




The following Declaration of Income may be submitted for consideration for provincial drug
coverage after it has been determined you do not qualify for the federal Guaranteed Income
Supplement (GIS).

Name                                                                        Date of Birth
                                                                                            DD   MM    YYYY

Mailing Address


Telephone                                    Language:        English       French

NB Medicare No.                                      Social Insurance No.

Spouse's Name                                                               Date of Birth
                                                                                            DD   MM     YYYY

NB Medicare No.                                      Social Insurance No.

Is this declaration to be assessed for both you and your spouse (if eligible).       Yes          No

IMPORTANT: You are not eligible to receive benefits from the New Brunswick Prescription Drug
           Program if you are or will continue receiving prescription drug benefits from a
           private insurance company after the age of 65.

 Applicant is eligible for the New Brunswick Prescription Drug Program if:
        You are a single applicant 65 years of age or older and have a total income of less than
        $17,198
        Both you and your spouse are 65 years of age or older and your combined total income is less
        than $26,955
        You are 65 years of age or older, your spouse is under age 65 and you have a combined total
        income of less than $32,390.

                       Mail to: The New Brunswick Prescription Drug Program
                            PO Box 690, Moncton, New Brunswick E1C 8M7
                                      or Fax to: 1-888-455-8322

                                 For assistance please contact us by:
                                      Telephone: 1-800-332-3692
                                         Fax: 1-888-455-8322
                                       E-mail: inquiry@nbpdp.ca

                                          - Continued on Next Page -                                   FORM-156(B) 06/08
When completing this Declaration of Income, the breakdown of the yearly income reported should be
that of the previous calendar year. All income must be indicated whether taxable or non-taxable.
Please enclose a photocopy of your Notice of Assessment from Canada Revenue Agency when
declaring a loss that lowers your total yearly income to within the income limits stated on the previous
page.
Income Source - previous calendar year                                        Applicant's Spouse's
                                                                                Yearly     Yearly
                                                                              Breakdown Breakdown
1. Old Age Security (T4A (OAS) Box 18
2. Net Federal Supplements (T4A (OAS) Box 21)
3. Widow's Pension or Spousal Allowance (T4A (OAS) Box 21)
4. Canada or Quebec Pension (T4A (P) Box 20)
5. Social Assistance (T5007 Box 11)
6. Other Pensions or Superannuation (Please Specify)
7. U.S. Social Security (Must be in Canadian Funds)

8. War Veterans Allowance (Must be indicated even if non-taxable)
9. Disability Benefits (Includes War Disability Pension)
10. Workers’ Compensation Benefits (T5007 Box 10)
11. Employment Insurance (T4E Box 14)
12. Other Insurance Benefits (Please Specify)
13. Interest, Dividends, RRSP or Other Investment Income
14. Income from Estate (Must be indicated even if non-taxable)
15. Capital Gains (Amount indicated on line 127 of tax return)
16. Rental Income (Amount indicated on line 126 of tax return)
17. Support Payments
18. Employment or Self-Employment
    (Business, Professional, Commission, Farming, Fishing)
19. Other Income (Please Specify)
TOTAL (Yearly)                                                               A                B
                                                    Total Income Combined          C


I hereby declare that I currently do not have prescription drug coverage through a private insurer and
that the information contained in this application and any document attached is correct,
complete and fully discloses all income.

Applicant's (or Trustee's) Signature                                          Date

Spouse's (or Trustee's) Signature                                             Date

				
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