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1 DS2444A Rev. 2019-07 Remove this page and keep it for your Application - General InformationSubmit the AISH Application and supporting documents by:1. Complete Part A Applicant Information, and use the Application Checklist on the next page to gather copies of the documents you must provide. Part B Medical Report to your doctor to complete. You will 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 add to Part A of your mailing them to PO Box 17000 Station Main, Edmonton, AB, T5J 4B3; or taking them to your nearest AISH office / Alberta Supports Centre; or submitting them online at them to 587-469-3006 (Edmonton Area) or 1-877-969-3006; or IntroductionThe Assured Income for the Severely Handicapped (AISH) program provides financial and health benefits to eligible Albertans with severe and permanent disabilities.

2 Depending on your situation, these benefits may include: A living allowance Personal benefits Health benefits Child benefitsApplying for AISHUse Your Guide to Completing the AISH Application to help you fill in the AISH application and know which documents you need to include. 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 to find an Alberta Supports Centre in your area. The AISH Application has 2 parts:Part A: Applicant Information (for you to complete)Part B:Medical Report (for your doctor to complete)Follow these steps:After Part A and Part B 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 you need more space for any sections, you may attach additional pages.

3 You may also attach any other relevant letters, documentation, or materials to support your personal information you provide is being 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 then be used and disclosed in the application process, for ongoing eligibility verification, and for delivery of those programs, benefits or services offered by the Government of Alberta under Alberta Supports, if eligibility is 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.

4 To see the list of the programs, including the legislation authorizing each program, please click 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 Rev. 2019-07 Remove this page and keep it for your Checklist InstructionsUse this checklist to make sure you include copies of all the documents that are required for your AISH application. Refer to Your Guide to Completing the AISH Application for more information and examples of the documents you may for Section 1 - Information About YouCopy of identification document(s) that shows your full legal name, date of birth, recent picture, and signature. Proof that you live in Alberta showing your street or rural land address, not a post office of your Record of Landing if you immigrated to Canada under sponsorship within the last for Section 2 - Spouse/Partner InformationCopy of identification document(s) for your spouse or partner that shows their full legal name, birth date, recent picture, and for Section 3 - Dependent Children InformationCopy of identification document(s) for any dependent children you or your partner have thatshows full legal name and date of for Section 4 - Trustee/Power of Attorney InformationCopy of a letter or document that shows the legal authority of a person or organization to act asyour Trustee or under a Power of for Section 8 - Income InformationCopy of document(s)

5 For all income you or your spouse or partner for Section 9 - Asset InformationCopy of document(s) for all assets you or your spouse or partner avoid delays with your application, please make sure you: answer all questions that apply to your situation, provide all documents, and sign the Declaration and do not submit original documents as they will not be returned to Rev. 2019-07 Part A - Page 1 of 9 File Section 4 AISH Application - Part A Applicant InformationDS2444 AYour SituationIf any of the following apply to your situation, you may not need to complete the entire Section 6 Employment History and Section 7 Education and Training History, and provide your medical documentation instead of completing Part B of the application, if:I am receiving end-of-life palliative care, and/or have been diagnosed with a terminal have been assessed as needing long term care or designated supportive living.

6 Skip Section 8 Income Information and Section 9 Asset Information, if:I am receiving Income Support benefits from Alberta Part A of the application and do not complete Part B, unless contacted by an AISH worker, if:I have applied for, or am applying for, the Persons with Developmental Disabilities (PDD) program. Contact an AISH office to find out how to apply, if:I left the AISH program less than 2 years ago and my medical condition has not the entire application, if:None of the above 1 - Information About YouProvide 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).Last NameMiddle NameFirst NameLast Name on Birth Certificate (if different)Other Preferred First Name (alias)GenderMaleFemaleSocial Insurance Number (SIN)Alberta Personal Health NumberHome PhoneOther Phone (if applicable)Marital Status (check one) (if married or in a partner relationship please fill out Partner Information section)SingleMarried PartnerSeparated from Spouse or PartnerDivorcedWidowedAre you a resident of Alberta?

7 YesNoWhat is your citizenship/immigration status? Canadian Citizen Permanent ResidentSponsored ImmigrantOther, specify:If Yes, indicate sponsorship start date and end Date yyyy-mm-ddEnd Date yyyy-mm-dd(include copy of Record of Landing)Check the box that describes your living situationRentOwnLive with familyShelterFacilityInstitutionGroup homeOtherApartment Unit #Street or Land Address where you liveCity/TownProvince/TerritoryPostal CodeMailing Address (if different from above)City/TownProvince/TerritoryPostal CodeDate of Birth:Year MonthDayDS2444A Rev. 2019-07 Part A - Page 2 of 9 File Section 4 Section 2 - Spouse/Partner InformationDo you have a spouse/partner?YesNoProvide a copy of identification document(s) for your spouse/partner that shows their full legal name, date of birth, recent picture, and NameFirst NameMiddle NameLast Name on Birth Certificate (if different)Other Preferred First Name (alias)GenderMaleFemaleSocial Insurance Number (SIN)Is your spouse/partner currently receiving AISH?

8 YesNoIf No, go to Section of Birth:Year MonthDaySection 3 - Dependent Children InformationLast NameFirst NameMiddle NameIf 18/19 years, is child attending high school?YesNoDoes this child live with you?YesNoProvide a copy of identification document(s) for any dependent child(ren) that includes the child's full legal name and date of you have a dependent child(ren)?YesNoIf No, go to Section of Birth:Year MonthDayLast NameFirst NameMiddle NameIf 18/19 years, is child attending high school?YesNoDoes this child live with you?YesNoDate of Birth:Year MonthDayLast NameFirst NameMiddle NameIf 18/19 years, is child attending high school?YesNoDoes this child live with you?YesNoDate of Birth:Year MonthDaySection 4 - Trustee/Power of Attorney InformationTrustee/Attorney Last NameTrustee/Attorney First NameTrustee/Attorney Phone NumberMailing AddressCity/TownProvince/TerritoryPostal CodeDo you have a Trustee or someone currently acting under a Power of Attorney?

9 YesNoIf No, go to Section 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).DS2444A Rev. 2019-07 Part A - Page 3 of 9 File Section 4 Section 5 - Medical InformationDoctorsWho is your current family doctor?NamePhoneAddressCity/TownProvince /TerritoryPostal CodeHave you been treated by doctors or specialists other than your family doctor during the past two years? If yes, please provide:YesNoNameType of Doctor/SpecialistPhoneAddressCity/TownPr ovince/TerritoryPostal CodeNameType of Doctor/SpecialistPhoneAddressCity/TownPr ovince/TerritoryPostal CodeDescribe your medical condition and the impact it has on you and your ability to work. Add more pages if you need more space. Medical ConditionDS2444A Rev.

10 2019-07 Part A - Page 4 of 9 File Section 4 Section 6 - Employment HistoryHave you ever been employed?YesNoIf No, proceed to Section you need to add more Employment History, add more Name (indicate if self-employed)Start date yyyy-mmAre you currently working with this employer? YesNoIf No, employment end date yyyy-mmFull-timePart-timeSeasonal/Sporad icVolunteer/UnpaidOtherOccupation / role / type of work Reason for leaving this job (if applicable)Because of your medical conditionOtherEmployer Name (indicate if self-employed)Start date yyyy-mmAre you currently working with this employer? YesNoIf No, employment end date yyyy-mmFull-timePart-timeSeasonal/Sporad icVolunteer/UnpaidOtherOccupation / role / type of work Reason for leaving this job (if applicable)Because of your medical conditionOtherEmployer Name (indicate if self-employed)Start date yyyy-mmAre you currently working with this employer?