AISH Application - General Information

Protected B (when completed)

Introduction
The Assured Income for the Severely Handicapped (AISH) program provides financial and health benefits to eligible
Albertans with severe and permanent disabilities. Depending on your situation, these benefits may include:
 A living allowance  Personal benefits  Health benefits  Child benefits

The personal information you provide is collected to determine your eligibility for different social-based supports and
benefits offered by the Government of Alberta under Alberta Supports. If you choose to apply, the personal information
you provide will be used and disclosed in the application process. If eligibility is confirmed, the information will be used for
ongoing eligibility verification, and the delivery of programs, benefits or services offered by the Government of Alberta
under Alberta Supports.
The personal information provided to Alberta Supports is collected, used and disclosed under the authority of sections
33-40 of the Freedom of Information and Protection of Privacy Act and various statutes establishing the programs
included in Alberta Supports. To see the list of the programs, including the legislation authorizing each program, please
go to https://open.alberta.ca/publications/a45p1 or request a printed copy.

If you have questions about the collection of your personal information, please contact the Alberta Supports Contact
Centre toll-free at 1-877-644-9992, from 7:30 a.m. to 8:00 p.m. every Monday to Friday, except statutory holidays.
Applying for AISH
Use Your Guide to Completing the AISH Application to help you fill in the AISH application. Documents required to
accompany the application will be noted in each section. Get help if you need it, by:
 having someone help you complete the application,
 calling the Alberta Supports Contact Centre at 1-877-644-9992, or
 contacting or visiting an AISH office listed at the back of the guide or go to alberta.ca/alberta-supports.aspx to
find an Alberta Supports Centre in your area, to schedule an appointment.
If you need more space for any sections, you may attach additional pages. You may also attach any other relevant
letters, documentation, or materials to support your application.

The AISH Application has two parts:

Follow these steps:
1. Complete Applicant Information, and use the Application Checklist in Your guide to completing the AISH application
to gather copies of the documents you must provide.
2. Take Medical Report to your doctor to complete. You may have to pay a fee to the doctor to complete the report. If
you need help paying the fee, contact the Alberta Supports Contact Centre for options. The doctor can send the
Medical Report, with supporting documents directly to AISH and give you a copy, or the doctor can send the report
and documents to you, to include with your application.
3. Submit the AISH Application and supporting documents by:
 submitting them online at https://aish-apply.alberta.ca; or
 faxing them to 587-469-3006 (Edmonton Area) or 1-877-969-3006; or
 mailing them to PO Box 17000 Station Main, Edmonton, AB, T5J 4B3.
After your application and medical reports are submitted to AISH:
You will be contacted by phone or mail:
 if more information is needed; and/or

 once a decision is made about your eligibility.

DS2444A Rev. 2022-05

 Your Situation
If any of the following apply to your situation, you may not need to complete the entire application.
Skip Section 5 Employment and Section 6 Education and Training History, and provide medical documentation instead of
completing the Medical Report, if:
You are receiving end-of-life palliative care, and/or have been diagnosed with a terminal illness.
You have been assessed as needing long-term care or designated supportive living.
Skip Section 7 Income Information and Section 8 Asset Information, if:
You are receiving Income Support benefits from the Government of Alberta.
Submit the application and do not complete Medical Report, unless contacted by an AISH worker, if:
You have applied for, or are applying for, the Persons with Developmental Disabilities (PDD) program.
Contact an AISH office to find out how to apply, if:
You left the AISH program less than two years ago and your medical condition has not changed.
Complete the application, if:
None of the above apply.

DS2444A Rev. 2022-05

 AISH Application
DS2444A Applicant Information
Section 1 - Information About You
Provide a copy of identification document(s) that shows your full legal name, date of birth, recent picture, and signature,
proof you live in Alberta, and Record of Landing (if applicable). Do not submit original documents, as they will not be
returned to you.
Last name First name Middle name

Last name on birth certificate (if different) Other preferred first name

Date of birth: Day Month Year Gender Social Insurance Number (SIN)
Male Female Gender diverse Prefer not to say
Alberta Health Number Home phone Other phone (if applicable)

Email address

Marital Status (check one) (if married or in a partner relationship please fill out Partner Information section) Are you a resident of
Single Married Partner Separated from spouse or partner Divorced Widowed Alberta? Yes No

What is your citizenship/immigration status? If Yes, indicate sponsorship start date and end date.

Canadian citizen Permanent resident Sponsored immigrant

(include copy of Record of Landing) Start date dd-mm-yyyy End date dd-mm-yyyy
Other, specify:

Check the box that describes your living situation Rent Own Live with relatives Shelter No fixed address
Long-term care facility Institution Public/social housing
Group home Other
Unit # Address where you live

City/town Province Postal code

Mailing address (if different from above)

City/town Province Postal code

Section 2 - Spouse/Partner Information

Do you have a spouse/partner? Yes No If no, go to Section 3.
Provide a copy of identification document(s) for your spouse/partner that shows full legal name, date of birth, recent
picture, and signature.
Last name First name Middle name

Last name on birth certificate (if different) Other preferred first name

Date of birth: Day Month Year Gender Social Insurance Number (SIN)
Male Female Gender diverse Prefer not to say

Is your spouse/partner currently receiving AISH?

Yes No

DS2444A Rev. 2022-05 Page 1 of 8

File Section 4
 Section 3 - Dependent Child(ren) Information
Do you have a dependent child(ren)? Yes No If no, go to Section 4.
Provide a copy of identification document(s) for any dependent child(ren) that includes the child's full legal name and
date of birth.
Last name First name Middle name

Date of birth: Day Month Year If 18/19 years of age, is child attending high school? Does this child live with you?
Yes No Yes No

Last name First name Middle name

Date of birth: Day Month Year If 18/19 years, is child attending high school? Does this child live with you?
Yes No Yes No

Last name First name Middle name

Date of birth: Day Month Year If 18/19 years, is child attending high school? Does this child live with you?

Yes No Yes No

If you need to note an additional child(ren), attach additional page(s).

Section 4 - Trustee/Power of Attorney Information

Do you have a Trustee or someone currently acting under a Power of Attorney? Yes No, If no, go to Section 5.

Provide a copy of a letter or document for a person or organization that shows their legal authority to act as your trustee
or under a power of attorney (attorney).
Trustee/attorney first name Trustee/attorney last name Trustee/attorney phone number

Mailing address City/town Province Postal code

If you need to add more employment history, attach additional page(s).

Section 5 - Employment History

Have you ever been employed? Yes No If no, proceed to Section 6.
Employer name (indicate if self-employed)

Start date mm-yyyy Do you currently work for this employer? If No, employment end date mm-yyyy

Yes No

Full-time Part-time Seasonal/occasionnal Volunteer/unpaid Self-employed Other

What was your job/role when you worked with this employer?

Reason for leaving this job (if applicable)

Contract ended Laid off (company closing or downsizing) Legal reasons Medical condition New job

Pursue education or training Retire Seasonal/temporary/casual Transportation to and from work

Workplace performance/relationship issues Work schedule/location Other, explain

If you need to add employment history, attach additional page(s).

DS2444A Rev. 2022-05 Page 2 of 8

File Section 4
Employer name (indicate if self-employed)

Start date mm-yyyy Do you currently work for this employer? If No, employment end date mm-yyyy

Yes No

Full-time Part-time Seasonal/occasionnal Volunteer/unpaid Self-employed Other

What was your job/role when you worked with this employer?

Reason for leaving this job (if applicable)

Contract ended Laid off (company closing or downsizing) Legal reasons Medical condition New job

Pursue education or training Retire Seasonal/temporary/casual Transportation to and from work

Workplace performance/relationship issues Work schedule/location Other, explain

If you need to add employment history, attach additional page(s).
Employer name (indicate if self-employed)

Start date mm-yyyy Do you currently work for this employer? If No, employment end date mm-yyyy

Yes No

Full-time Part-time Seasonal/occasionnal Volunteer/unpaid Self-employed Other

What was your job/role when you worked with this employer?

Reason for leaving this job (if applicable)

Contract ended Laid off (company closing or downsizing) Legal reasons Medical condition New job

Pursue education or training Retire Seasonal/temporary/casual Transportation to and from work

Workplace performance/relationship issues Work schedule/location Other, explain

If you need to add employment history, attach additional page(s).
Employer name (indicate if self-employed)

Start date mm-yyyy Do you currently work for this employer? If No, employment end date mm-yyyy

Yes No

Full-time Part-time Seasonal/occasionnal Volunteer/unpaid Self-employed Other

What was your job/role when you worked with this employer?

Reason for leaving this job (if applicable)

Contract ended Laid off (company closing or downsizing) Legal reasons Medical condition New job

Pursue education or training Retire Seasonal/temporary/casual Transportation to and from work

Workplace performance/relationship issues Work schedule/location Other, explain

If you need to add employment history, attach additional page(s).

DS2444A Rev. 2022-05 Page 3 of 8

File Section 4
 Section 6 - Education/Training History
What is the highest education level you have completed?

No formal education Grade 1-6 Grade 7-9 Grade 10-12 GED High school certification of achievement

High school diploma Some college/university Some trades/technical College/university

School/college/university name

Program of study

Degree/diploma obtained (includes all levels of degrees) Last year attended yyyy

Training completed Year yyyy

Training or upgrading (indicate training completed and year)

Technical/trades/journeyman

School/provider

Course Level completed

Certificate or diploma obtained Year yyyy

Non credential (includes college preparatory and English as a second language) Last year attended yyyy

What steps have you taken to find work or training suitable for your medical condition(s)?

Are you currently attending an education or training program? Yes No

If yes, school/provider Location

Program of study Date started mm-yyyy Expected completion date mm-yyyy

Are you planning to take further training or upgrading in the near future? Yes No
If yes, complete the following.
School/provider

Program of study Date started mm-yyyy Expected completion date mm-yyyy

What are your goals upon completing training?

DS2444A Rev. 2022-05 Page 4 of 8

File Section 4
 Section 7 - Income Information
Indicate yes if you and/or your spouse/partner have received any of the following income. If you answer yes, provide the average
monthly amount and include supporting documentation. Fill in all types you are currently receiving which apply to you and your
spouse. For more information about how income is treated, please refer to Your Guide to AISH. Refer to Your Guide to Completing the
AISH Application for more information and examples of documents you will need.

Income type
Applicant Spouse/partner
If yes, average If yes, average
monthly amount monthly amount
Employment
Yes $ Yes $
(provide 3 most recent months of pay stubs)

Self-employment Yes Yes

$ $

Employment Insurance (EI) Yes $ Yes $

Canada Pension Plan (CPP) Yes $ Yes $

Old Age Security (OAS) Yes Yes

$ $

Pension from previous employment Yes $ Yes $

Disability/wage loss insurance Yes $ Yes $

Income from trust account(s) Yes $ Yes $

Income from investments Yes $ Yes $

Income from a rental property Yes Yes

$ $

Life insurance income Yes $ Yes $

Guaranteed income supplement Yes $ Yes $

Spousal support/alimony Yes $ Yes $

Workers’ Compensation Benefits Yes $ Yes $

1. Do you or your spouse/partner have other sources of income? Yes No

If yes, specify the type of income, amount and provide documentation.

2. Have you or your spouse/partner received a special payment in the past 12 months? Yes No

If yes, specify the type of payment, amount, date it was received, and provide documentation. (See the list of special payments in
Section 7 of the Your Guide to Completing the AISH Application.)

DS2444A Rev. 2022-05 Page 5 of 8

File Section 4
 Section 8 - Asset Information
Fill in only the fields that apply to you and your spouse/partner. Provide only the approximate value in each relevant field and provide
documentation. For more information about how assets are treated, please refer to Your Guide to AISH. Refer to Your Guide to
Completing the AISH Application for more information and examples of documents you will need.

Applicant Spouse/partner
If yes, If yes,
approximate value approximate value
Bank account(s)
Yes Yes
include all bank account types $ $

Cash and uncashed cheques Yes $ Yes $

Guaranteed Investment Certificates (GICs),
term deposits Yes $ Yes $
Registered Retirement Savings Plan (RRSP), Yes Yes
Registered Retirement Income Fund (RRIF) $ $

Annuities Yes $ Yes $

Locked-In Retirement Account (LIRA)* Yes $ Yes $

Registered Disability Savings Plan (RDSP)* Yes $ Yes $

Registered Education Savings Plan (RESP) Yes $ Yes $

Tax-Free Savings Account (TFSA) Yes $ Yes $

Stocks and/or bonds Yes $ Yes $

Trust funds Yes $ Yes $

Life insurance (cash surrender value) Yes $ Yes $

Vehicle(s)** Yes Yes
How many do you have? $ $

Vehicle adapted for a disability** Yes $ Yes $

Recreational vehicle(s) (e.g. motorhome, boat, Yes
Yes
snowmobile, etc.) $ $

Other vehicle Yes $ Yes $

Home/principal residence* Yes $ Yes $

Recreational property Yes $ Yes $

Rental property Yes $ Yes $

Farm Yes $ Yes $

Provide the following documents: most recent property tax assessment, mortgage documents, balance sheet, business asset
insurance, list of all farm vehicles, farm insurance, machinery and equipment (include current value, year, make and model).
Do you live on a home quarter section?* Yes $ Yes $
Do you own land other than the home quarter
Yes $ Yes $
section?
Business Yes $ Yes $
Provide the following documents: most recent property tax assessment, mortgage documents, business income, tax notice of
assessment, business income tax return, accounting statement/balance sheet, business asset insurance.

* These assets are exempt and do not affect your eligibility for AISH benefits. However, you must report them along with other
assets listed above to help AISH understand your financial situation and determine eligibility.
** These assets may be exempt depending on your situation.

DS2444A Rev. 2022-05 Page 6 of 8

File Section 4
 Section 9 - Declaration
1. I declare the information I am giving about me, my spouse/partner (if applicable) and my dependent child(ren) (if
applicable) is true and complete, and I understand that intertionally withholding information or giving false or
incomplete information is an offence which could result in criminal charges.
2. If I am a guardian, co-decision-maker, agent, Trustee or attorney (under a power of attorney), I understand what this
declaration means as it applies to the applicant.

Applicant name (print) Date* dd-mm-yyyy Signature

Guardian/co-decision-maker/agent name (print) Date* dd-mm-yyyy Signature

Trustee/attorney name (print) Date* dd-mm-yyyy Signature

*Date consent is effective.

Section 10 - Consents
AISH Consent
I give my permission to person, agency, organization, institution or other source to give the AISH program and/or AISH
contracted services any information about my household situation, education and training, employment, and finances
AISH requests to determine my eligibility for AISH. I understand I may withdraw my consent, in writing, at any time.

Please note that while consent can be withdrawn, in writing, at any time, doing so may impact your eligibility for AISH benefits.

Applicant name (print) Date* dd-mm-yyyy Signature

Guardian/co-decision-maker/agent name (print) Date* dd-mm-yyyy Signature

Trustee/attorney name (print) Date* dd-mm-yyyy Signature

*Date consent is effective.

If you would like to name a person or organization the AISH program can contact or who can contact the AISH program
about your application, please provide the following information:

Name of person/organization (print) Phone number

Canada Revenue Agency Consent

I authorize Canada Revenue Agency to release information required from my tax file to the Alberta Ministry of Community
and Social Services. The information will be relevant to and used solely for the purpose of determining and verifying my
eligibility, or the eligibility of my co-habiting partner, for benefits under the Assured Income for the Severely Handicapped
Act (c. A-45.1, 2006), and the general administration and enforcement of the benefit programs. This authorization is valid
for the taxation year prior to the year of signature of this consent, the current taxation year, and each subsequent
consecutive taxation year for which assistance is requested. I understand that if I wish to withdraw this consent, I may do
so in writing to the Alberta Ministry of Community and Social Services.

Applicant name (print) Date* dd-mm-yyyy Signature

Trustee/attorney name (print) Date* dd-mm-yyyy Signature

Spouse/partner name (print) (if applicable) Date* dd-mm-yyyy Signature

*Date consent is effective.
DS2444A Rev. 2022-05 Page 7 of 8
File Section 4
 Section 11 Continued - Consents

Canada Pension Plan - Disability (CPP-D) Consent

1. I understand the AISH program requires applicants to use all available income, and that CPP-D is a benefit I may be
entitled to.

2. If I am eligible for AISH benefits, I agree to have a CPP-D representative decide if I am eligible for CPP-D benefits. If
the CPP-D representative decides I am not eligible for CPP-D based on my earnings and contributions, they will share
that information with AISH and I will not need to apply for CPP-D.
3. To decide my eligibility for CPP-D, I give my permission to AISH to share the following information with CPP-D:

a. AISH Medical Report filled out by my doctor, and any other reports or documents that will
help the programs decide my medical eligibility; and
b. my completed AISH Application form.

4. To decide my eligibility for, and the amount of my AISH benefits, I give my permission to CPP-D to share the following
information with AISH:
a. CPP-D will tell AISH whether or not I need to apply for CPP-D; and
b. CPP-D's decision about my CPP-D benefit and the amount of the benefit I will receive.
5. I understand I may withdraw my consent, in writing, at any time, and that this consent is in place for three years from
the date* I (or my guardian/co-decision-maker/agent/Trustee/attorney) sign it. Please note: Withdrawing consent may
impact your eligibility for AISH benefits.

Applicant name (print) Date* dd-mm-yyyy Signature

Guardian/Co-decision-maker/agent name (print) Date* dd-mm-yyyy Signature

Trustee/Attorney name (print) Date* dd-mm-yyyy Signature

*Date consent is effective.

DS2444A Rev. 2022-05 Page 8 of 8

File Section 4