The information you provide in this form will be used to determine and verify your eligibility for Employment and Income Assistance.
Collection, use and disclosure of this information is done under the authority of the applicable legislations
(e.g. Manitoba Assistance Act, Freedom of Information and Protection of Privacy and Personal Health Information Act).
If you have any questions about the collection of your information, please contact the Department of Families Access
and Privacy Coordinator at (204) 945-2013 or 205 – 114 Garry Street, Winnipeg MB R3C 4V4.