CPP Disability Completed Example Instruction
CPPD BENEFITS ADMINISTRATION INSTRUCTION FORM Client Name: Address: Phone: James Doe 9999 – 99 Street, Someplace Alberta A1A 1A1 (780) 400-0000 Social Insurance Number: Do you wish to receive direct deposits: Yes 999 999 999 No If yes, please select one of the following: I have attached a blank cheque I have attached a direct deposit slip from my bank I request that my CPPD worker attach a copy of my CPPD direct deposit form One Time Expenses: In order to request funds for a one time expense, you only need to complete the top section, this section and the “Primary Contact Person” section below. Name of Payee ______________ Address Purpose __________________ __________ Monthly Expense Name of Payee Address 1. Telus Account# 123 – 45 Street Edmonton, AB 99999 Amount Schedule _________ one time payment CPPD Monthly Benefit Amount $1,000.00 Payment Purpose Amount Schedule Telephone $45.00 Monthly Rent $350.00 Monthly Monthly 2. Wildwood Apts Account# 9999 - 99 Street Someplace, AB 3. City of Someplace Account# 1111 – 11 Avenue Edmonton, AB Bus Pass $50.00 4. John Doe Account# Direct Deposit Spending $30.00 ($130.00 monthly) 5. Epcor Account# 123456 1234 – 5 Street Calgary , AB Power $55.00 6. John Doe Account# Direct Deposit Food $100.00 Savings $ 70.00 7. Account# Total Monthly Expenses Primary Contact Person: Name: Jane Doe Address: 8888 – 88 Street Primary Contact Sign Here Signature You Sign Here Signature Each Tues Monthly Twice a Month 1,000.00 Phone: (780) 500-0000 Fax: (780) 600-0000 E-Mail Address: [email protected] Date Here Date Date Here Date Monthly expenses may include such things as: Rent Board and room Food Utilities Telephone Recreation Program costs Personal allowance Savings Transportation / bus pass Clothing Example of payment schedule would be: Monthly Bi-monthly Bi-weekly Weekly (Calculate monthly total by multiplying by 52 weeks a year and then dividing by 12 months)
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