Employment and Emploi et PROTECTED B WHEN COMPLETED

Social Development Canada Développement social Canada

Repayment Assistance Plan for Borrowers with Disabilities

Disability-Related Expenses Form

Instructions: Please print clearly, and sign and complete the two (2) pages of this form.

Section 1 - What Are Disability Related Expenses

The Repayment Assistance Plan for Borrowers with Disabilities (RAP-D) considers expenses that a borrower may have that are directly
related to their permanent disability, or persistent or prolonged disability. These Disability Related Expenses (DREs) may have an impact
on your eligibility for RAP-D or on the amount of your RAP revised monthly payment. Please use this form to provide information about any
such DREs.

DREs must only include expenses that are not covered by an insurance plan, or a private or publicly funded program, e.g. Provincial
Disability Support Program. In addition, DREs must correspond to each applicable month of income you provided in your on-line or paper
application for RAP-D.
The following are examples of DREs that could be related to your permanent disability, or persistent or prolonged disability:
• Essential medical, dental, hearing, optical, and other expenses, such as chiropractic care, registered massage therapy, or
psychological/psychiatric care, that are directly related to your permanent disability, or persistent or prolonged disability. We require
documentary proof that these DREs were prescribed by a Canadian physician or nurse practitioner.
• DREs directly related to accommodation of your permanent disability, or persistent or prolonged disability, such as learning disability
expenses, readers, assistive devices, and technology.
• Home or automobile modifications required to accommodate your permanent disability, or persistent or prolonged disability (not
cosmetic or regular maintenance).
For the purpose of properly assessing your incurred DREs, the Canada Student Financial Assistance Program (CSFA Program)
requires the following:
1. Documentary proof of insurance coverage that highlights the portion that is not paid or reimbursed by an insurance plan, or a privately
or publicly funded program.

2. Documentary proof of the payment(s), in the form of a receipt or statement of account, that prove the DREs occurred during each
applicable month of income you provided in your on-line or paper application for RAP-D.

3. A statement briefly describing the nature of your permanent disability, or persistent or prolonged disability.
4. Documentary proof that treatments you are claiming (e.g. registered massage therapy, acupuncture, etc.) were prescribed
by a Canadian physician or nurse practitioner.

Section 2 - Applicant Information

Last Name First Name Initials

Date of birth (YYYY-MM-DD) Social Insurance Number (S.I.N.) Do you reside in Canada?
Yes No

Mailing address (street number and name) Apt. No.

City Province Postal Code Primary Telephone Number

Section 3 – Disability Related Expenses Information

How are the DREs related to your permanent disability, or persistent or prolonged disability?

Please fill in the total amount that you have spent on the uninsured or unfunded portion of your DREs below.
* In order for the CSFA Program to assess your DREs, you must attach proof of your expenses in the form of receipts.
Prescription Drugs $
Other Expenses $
Total $
Do you have insurance coverage, or coverage through a private or publicly funded program? Yes No
* If yes, you must include proof of your coverage, such as receipts that clearly show the portion covered.

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Section 4 - Applicant's Signature and Protection of Personal Information

You certify that all information you have provided is complete and true, to the best of your knowledge, and understand that it is an offence
to make a false or misleading claim and/or statement.

You authorize the federal government, the provincial/territorial government(s), the National Student Loans Service Centre, the Canada
Apprentice Loan Service Centre, consumer credit grantor(s), credit bureau(s), credit reporting agency(ies), any person or business with
whom you have or may have had financial dealings and your Financial Institution(s), to directly or indirectly collect, retain, use and
exchange among themselves any personal information related to this application for the purposes of carrying out their duties under the
Federal Act(s) and Regulation(s) and/or the applicable Provincial Act(s) and Regulation(s) relating to student and/or apprentice financial
assistance including for administration, enforcement, debt collection, audit, verification, research, and evaluation purposes.

If you entered into any agreements under the Canada Student Loan Act, the Canada Student Financial Assistance Act, or the Apprentice
Loans Act or associated provincial loan programs, or signed any promissory notes while you were a minor, you hereby ratify those
agreements and notes.

Application Date
Applicant's Signature
(YYYY-MM-DD)

Privacy Notice Statement

The information you provide is collected under the authority of the Canada Student Financial Administration Act (CSFAA) and Regulations, the Canada Student Loans Act (CSLA)
and Regulations, and the Apprentice Loan Act (ALA) and Regulations for the administration of the Canada Student Financial Assistance Program (CSFA Program) and/or the
Canada Apprentice Loan (CAL). The Social Insurance Number (SIN) is collected under the authority of the Canada Student Financial Assistance Regulations (CSFAR), the
Canada Student Loan Regulations (CSLR), and the Apprentice Loan Regulations (ALR), and in accordance with the Treasury Board Secretariat Directive on the Social Insurance
Number, which lists the CSFAR, CSLR, and ALR as authorized users of the SIN. The SIN will be used as a file identifier, and, along with the other information you provide, will
also be used to validate your application, and to administer and enforce the CSFA Program and CAL.

Participation in the Repayment Assistance Plan (RAP) is voluntary. Refusal to provide personal information will result in your disability-related expenses not being assessed and
considered to determine your eligibility for RAP for borrowers with disabilities.

The information you provide may be shared with the federal government, the provincial/territorial government(s), the National Student Loans Service Centre, the Canada
Apprentice Loan Service Centre, consumer credit grantor(s), credit bureau(s), credit reporting agency(ies), any person or business with whom you have or may have had financial
dealings, and your Financial Institution(s), to directly or indirectly collect, retain, use, and exchange among themselves any personal information related to this application for the
purposes of carrying out their duties under the Federal Act(s) and Regulation(s) and/or the applicable Provincial Act(s) and Regulation(s) relating to student and/or apprentice
financial assistance, including for administration, enforcement, debt collection, audit, verification, research, and evaluation purposes. The information you provide may be
disclosed to Statistics Canada for statistical and research purposes.

Your personal information is administered in accordance with the CSFAA and CSFAR, CSLA and CSLR, the ALA and ALR, the Department of Employment and Social
Development Act, the Privacy Act, and other applicable laws. You have the right to the protection of, access to, and correction of your personal information, which is described in
Personal Information Banks ESDC PPU 030 and/or ESDC PPU 709. Instructions for obtaining this information are outlined in the government publication entitled, Info Source,
which is available at the following web site address: www.canada.ca/infosource-ESDC Info Source may also be accessed on-line at any Service Canada Centre. You have the
right to file a complaint with the Privacy Commissioner of Canada regarding the institution's handling of your personal information at:
https://www.priv.gc.ca/faqs/index_e.asp#q005.

Section 5 – Reconsideration of Other Expenses (Optional)

In the event that you have submitted an expense that is not considered to be directly related to your permanent disability, or persistent or
prolonged disability, you consent to allow:

• The expense(s) to be reviewed to determine if it qualifies as an exceptional expense(s) to be deducted from your gross income
amount under the CSFA Program’s reconsideration process; and
• You understand that expenses, such as credit card debt, student lines of credit, monthly utility costs, or expenses
associated with commuting and childcare, may not qualify as extraordinary, exceptional and/or unforeseen costs.
Exceptional Expenses
Exceptional expenses are those that result from unforeseen and unavoidable circumstances beyond the control of the Applicant, and, if
applicable, the Applicant's spouse or common-law partner, and include expenses that are not covered by an insurance plan, or a private
publicly funded program (e.g. Provincial Disability Support Program). Here are some common examples of exceptional expenses that can
be included under the CSFA Program’s reconsideration process:

• Expenses related to the care of a wholly dependent person (elderly or infirmed relative), as recognized by the Canada
Revenue Agency (CRA)
• Childcare and/or attendant expenses related to the care of a dependent child who has a disability
• Exceptional expenses related to marital breakdown (includes a common law spouse)
• Funeral Expenses
• Legal fees due to exceptional circumstances
• Emergency home repairs (not cosmetic or regular maintenance)
• Essential medical, dental, or optical expenses (expenses deemed necessary to maintain a person’s medical, dental, and/or
optical health, these do not have to be directly related to the Applicant’s permanent disability, or persistent or prolonged
disability, and may be incurred for an Applicant or any of the Applicant's direct family members.)

Application Date
Applicant's Signature
(YYYY-MM-DD)

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