Apply to the Senior's Independence Initiative

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Personal information on this form is collected under Section 31 (c) of the Freedom of Information and Protection of Privacy Act and will be used for administering the Social Assistance Act or the Supports for Persons with Disabilities Act. If you have any questions about this collection of personal information, you may contact the Manager of Administration, Social Programs, Department of Social Development & Housing, 902-368-5230.

Identification

First Name

Middle Initial

Last Name

Address 1

Address 2

City, Town, or Community

Province

Postal Code

For example C1B 0X1 or 12345

Country

Telephone Number

For example 902-555-5555

Email Address

Date of Birth

Personal Health Number (PHN)

Do you have a spouse?

Spouse Information

First Name

Last Name

Date of Birth

Personal Health Number (PHN)