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)