Supplemental Unemployment Benefit Application
(All applicable Forms must be completed 100% before submission)
Initial Screening Information
Please attach a copy of each of the required supporting documents:
Terms of Agreement
APPLICANT DECLARATION
I agree that the information provided can be relied upon by the Department of Financial Assistance to be true and correct to determine my eligibility for receipt of Supplemental Unemployment Benefit.
I fully understand the information requirements, conditions and terms of assistance stated at the time of interview and agree to provide any supporting material that the Department of Financial Assistance under the Supplemental Unemployment Benefit program may require.
I further understand that the department will request repayment of assistance received if:
I lastly understand that if false, misleading or inaccurate information is submitted, I will be under penalty of suspension or cancelation as stated in the Public Treasury (Administration and Payments) (Supplemental Unemployment Benefit) Regulations 2022 12(1)(a)(b)(c) and 14(1)(2)
CONSENT TO DISCLOSE AND VERIFY INFORMATION
I consent to release the information to an authorized representative of the Department of Financial Assistance for the purpose of determining and verifying my initial and ongoing eligibility for financial assistance by collecting information about myself.
I consent to release information relating to any assets, bank accounts, owned by me or jointly with other individuals, spouse, significant others, dependents or others.
I understand that this consent applies to inquiries made during a period of time which I have been in receipt of Supplemental Unemployment Benefits. I further understand that requests and responses may take the form of electronic data exchange.
Important Notice
In accordance with the Public Treasury (Administration and Payments) (Supplemental Unemployment Benefit) Regulations 2022, any person who knowingly makes any false statement or knowingly provides any false information will have committed an offence. Any person who commits an offence is liable on summary conviction to a fine of $1,500 or imprisonment for six months or to both such fine or term of imprisonment.
Household Monthly Expenses
Please do not put commas or dollar signs in the following fields.
Expenses:
Total Expenses: ${showExpenses}