Special needs assistance request form: Fill out & sign online

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Click ‘Get Form’ to open it in the editor.
Begin with Section 1 — Personal Information. Fill in your personal health number, last name, and first name. If applicable, include your spouse/partner’s details as well.
Provide your mailing address, including suite or apartment number, city, province, and postal code. Ensure all information is accurate for effective communication.
If you are applying for home repairs, enter your legal land description in the designated field.
Move to Section 2 — Assistance Requested. Refer to the Information Booklet for eligible expenses and list them along with their respective amounts.
In Section 3 — Authorization, provide the name and relationship of a contact person who can assist with processing your request.
Finally, complete Section 4 — Signature. Both you and your spouse/partner must sign and date the form to validate your request.

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