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Fair Entry Application

 

Primary Applicant Information

Document Guidelines

We ask for two items: proof of Medicine Hat address and proof of income

If your proof of income documents show your CURRENT address you need only include that ONE document as proof of address AND proof of income.

1. Proof of Medicine Hat address (P.O. boxes or rural route addresses are not accepted)

Below are the examples for the documents that will show your proof of address

• A copy of your Alberta Driver’s License

• A copy of your Alberta ID Card

• A copy of utility, telephone, or cable bill dated within the last 30 days

• A copy of a government document with your name and address dated within the last 30 days

• Signed lease agreements

2. Proof(s) of Income 

You can apply to Fair Entry with six different proofs of income:

  • Please submit a copy of ONE of these documents with your application.
  • A copy of the document MUST accompany your application for each member of your household 18 years or older.
  • If you are submitting documents on behalf of another person over the age of 18, you must complete an authorization consent form below.

1. Canada Revenue Agency: Notice of Assessment 

2. Assured Income for Severely Handicapped (AISH) Health benefit card from the current month 

3. Alberta Income Supports/Alberta Works Health benefit card from the current

4. Letter from a Registered Social Worker 

5. Resettlement Assistance Program Form 

6. For Independent Youth – a letter from a school principal or guidance counselor, or letter from Child and Youth Support Program of Alberta Children’s Services

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Household Members Information

Household members MUST be included here if you want them to be considered for approval to receive the Fair Entry Subsidy.

Remember: “household members” are anyone who resides at the same City of Medicine Hat address with you (the primary applicant) and are related to you by blood, marriage, common law relation or adoption.

 

Please click on "Add" button to add more household members to the list.

 


Consent and Statement

1. I declare that the statements made in this application are complete and correct to the best of my knowledge.

2. I understand that any misstatements or falsification of information may cause me to forfeit my rights to the use of the Fair Entry Program.

3. I understand that my application to the Fair Entry Program is to be dependent upon: a. Satisfactory proof of income and proof of residency documents b. Proper completion of the application form(s) including the household members information section(s)

4. I understand and authorize the City of Medicine Hat to contact me in matters pertaining to my application

5. I will notify the Fair Entry Program immediately if my, and/or my household members’ status changes.

By submitting this application/form you acknowledge and agree that any electronic signature provided by you herein is the same as a handwritten signature for the purposes of legality, validity, enforceability, and admissibility.

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Authorization Consent Form

If you are completing this application on behalf of someone else (anyone in your household that is over the age of 18 and would like to be included in this program) then please complete the section below, and ensure you include their proof of income information with your application, if applicable”.

I have read and understood this Application in its entirety and I give my consent to the applicant, whose contact information is stated in "Primary Applicant Information" section of this Application, to provide the City of Medicine Hat with my date of birth, relationship to the applicant, and the following other personal information on my behalf.

 

This Authority will remain in effect for one year from the date of signature unless previously revoked in writing to this office.

By submitting this application/form you acknowledge and agree that any electronic signature provided by you herein is the same as a handwritten signature for the purposes of legality, validity, enforceability, and admissibility.

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FOIPP Statement

The City of Medicine Hat is collecting the personal information on this form under of the authority of section 33(c) the Freedom of Information and Protection of Privacy Act for the purpose of operating a program of activity of the City of Medicine Hat. The City of Medicine Hat must collect personal information directly from the individual that the information is about unless another method of collection is authorized by the individual or by an enactment of Alberta or Canada. The personal information provided will be protected under Part 2 of the Freedom of Information and Protection of Privacy Act and will be used for the purpose of determining and verifying eligibility for the Fair Entry Program and for the regular administration and enforcement of the Fair Entry Program. Questions regarding the collection and use of personal information can be directed to the FOIPP Head of Local Body, City of Medicine Hat at clerk@medicinehat.ca.