Family Member Attestation for Employment Insurance …

1 SC INS5223 (2019-12-007) EPage 1 of 1 Service CanadaPROTECTED B WHEN COMPLETEDC laimant Name:SIN: Family Member Attestation for Employment Insurance Family Caregiver benefits or Compassionate care BenefitsIndividuals who are not Family members but are considered to be like Family can apply for Family Caregiver benefits and Compassionate care benefits . This form must be completed by the non- Family individual who wishes to claim Family Caregiver benefits or Compassionate care benefits . If possible, the patient should sign this form. If the patient is not an adult or is unable to sign this Attestation because of a physical or mental condition, the patient s legally authorized representative can sign the INFORMATION Last name:Given name(s):Date of birth (yyyy-mm-dd):HOME ADDRESSA partment number Street number and nameCity or townProvince, territory or statePostal or Zip codeCountry PATIENT'S REPRESENTATIVE (if applicable)Name of representative (please print)Relationship to patientPhone numberATTESTATIONI,(patient or representative name - please print)attest that(claimant name - please print)is considered to be like a Family Member for the purposes of (EI) Family Caregiver or Compassionate care benefits .

2 Patient or representative signatureDateThe information provided on this form is collected under the authority of the EI Act to determine eligibility for Family Caregiver or Compassionate care information provided may also be used for policy analysis, research and/or evaluation purposes, in which case, various sources of information under the custody and control of Employment and Social Development Canada may be linked. In some instances, information may be disclosed without consent according to the Department of Employment and Social Development Act (DESD Act).The personal information collected is administered in accordance with the EI Act and the Privacy Act. Individuals have the right to the protection of and access to their personal information. Information will be retained in the Personal Information Bank. Instructions for obtaining this information are outlined in the government publication entitled Info Source, a copy of which is located at all Service Canada Centres.

3 Info Source is also located at the following address.