Self-Directed Home Support Application

CLIENT INFORMATION

ELIGIBILE SERVICES:

• Sweeping
• Vacuuming
• Laundry
• Meal planning and preparation
• Light cleaning
• Clean bathrooms
• Light gardening/plant care
• Rotation of groceries
• Cleaning fridge/freezer
• Dusting
• Mopping
• Washing dishes
• Organization
• Change bedding and/or linens
• Light snow shoveling
• Respite
• Companionship

 Prior to remitting expenses to the Saddle Hills County Self Directed Home Support Program, I agree to the following: 

1. I, , acknowledge the information collected on these forms will be used to determine my eligibility to this program.
2. I am a resident of Saddle Hills County.
3. I understand this program is administered on a first-come, first-serve basis.
4. I understand that I am solely responsible for hiring someone to perform the eligible services described within this application. I cannot remit for any services that are not eligible under this program.
5. I am responsible for performing background and reference checks for whomever I hire.
6. I agree to submit only for completed work that is eligible as described in this application.
7. I understand that Saddle Hills County will pay a maximum of $400.00 per month for completed work.
8. If my application is approved, I agree to provide Saddle Hills County a direct deposit form and social insurance number.
9. I agree to notify the Saddle Hills County staff of any changes in my circumstances that would alter my agreement with them.
10. I understand that if a period of six (6) months passes without submitting a reimbursement, I will be automatically removed from the program and must reapply if I want to receive future reimbursements.
11. The subsidy will be terminated if the I am no longer eligible for these services.
12. I understand I will be issued a T4A statement
13. I agree that I have read and understand Saddle Hills County Policy AD69 - Self Directed Home Support Program

Declaration of Understanding

I fully understand all of responsibilities required of me by the Self-Directed Home Support Program.

I certify that the information I provided is true and complete to the best of my knowledge. I am aware that if such information has been falsified, I may be terminated from the Self-Directed Home Support Program.

Notice of Collection

Protection of Privacy - The personal information requested on this form is collected under the authority of Section 33 (c) of the Alberta Freedom of Information and Protection of Privacy Act and will be protected under Part 2 of that Act. It will be used for the purpose of addressing issues and concerns raised by members of the public and in case any follow-up information is required. Direct any questions about this collection to:  FOIP Coordinator, Saddle Hills County, RR 1, Spirit River, Alberta, Canada, T0H 3G0, 1-888-864-3760.