Cover Sheet - Service Canada

Canada / Spain Agreement
Applying for a Spanish Death and/or Survivor Benefit
Here is some important information you need to consider when completing your application.
Please ensure you sign the application. If you are signing with a mark, (for example: “X”) the signature of
a witness is required.
Your application must be supported by documentation. Please submit the documents requested. Failure
to complete the application and provide the requested documentation may result in delays in processing
your application.
Where original documents are specifically requested, originals must be submitted with your application.
You should keep a certified true copy of any originals you send us for your records. Some countries
require original documentation which will not be returned to you.
You may submit the original or a photocopy that is certified as true for any of the documents where
originals are not required. It is better to send certified copies of documents rather than originals. If you
choose to send original documents, send them by registered mail. We will return the original documents
to you. We can only accept a photocopy of an original document if it is legible and if it is a certified true
copy of the original. Our staff at any Service Canada centre will photocopy your documents and certify
them free of charge. If you cannot visit a Service Canada Centre, you can ask one of the following people
to certify your photocopy:
Accountant; Chief of First Nations Band; Employee of a Service Canada Centre acting in an official
capacity; Funeral Director; Justice of the Peace; Lawyer, Magistrate, Notary; Manager of Financial
Institution; Medical and Health Practitioners: Chiropractor, Dentist, Doctor, Pharmacist, Psychologist,
Nurse Practitioner, Registered Nurse; Member of Parliament or their staff; Member of Provincial
Legislature or their staff; Minister of Religion; Municipal Clerk; Official of a federal government department
or provincial government department, or one of its agencies; Official of an Embassy, Consulate or High
Commission; Officials of a country with which Canada has a reciprocal social security agreement; Police
Officer; Postmaster; Professional Engineer; Social Worker; Teacher.
People who certify photocopies must compare the original document to the photocopy, state their official
position or title, sign and print their name, give their telephone number and indicate the date they certified
the document.
They must also write the following statement on the photocopy: This photocopy is a true copy of the
original document which has not been altered in any way.
If a document has information on both sides, both sides must be copied and certified. You cannot certify
photocopies of your own documents, and you cannot ask a relative to do it for you.
Return your completed application, forms and supporting documents to:
International Operations
Service Canada
P.O. Box 250
Fredericton, NB E3B 4Z6
CANADA
Disclaimer:
This application form has been developed by external
sources in cooperation with Employment and Social
Development Canada. The content and language
contained in the form respond to the legislative needs
of those external sources.
I
CAN- E l
CONVENIO SOBRE SEGURIDAD SOCIAL ENTRE E S P A ~ A
Y CANADA
CONVENTION ON SOCIAL SECURITY BENVEEN SPAIN AND CANADA
CONVENTION DE S ~ C U R I TSOCIALE
~
ENTRE L'ESPAGNE ET LE CANADA
Vejez
Old Age benefits
Vieillesse
SOLlClTUD DE PRESTACIONES CONFORME A LA LEGISLACI~NESPA~~OLA
POR (1)
CLAIM FOR BENEFITS UNDER SPANISH LEGISLATION (I)
DEMANDE DE PRESTATIONS EN VERTU DE LA LEGISLATION ESPAGNOLE POUR (I)
lnvalidez
Disability benefits
lnvalidite
Muerte
Death benefits
D6cBs
Supewivencia
Survivor's benefits
Survivants
Titulo Ill del Convenio / Part 111 of the Convention 1 Titre Ill de la Convention
Artlculos 6 y 7 del Acuerdo Administratlvo
Articles 6 and 7 of the Administrative Agreement
Articles 6 et 7 de I1ArrangernentAdrninistratif
L o s r e c u a d ~ ~ ~ estdn resewados ai uso de la Administracldn canadlense
Boxes
are reserved for the Canadian Administration
Lescases
sont rBservBes A Mdministration canadienne
A CUMPUMENTAR EN TODO CASO / TO BE COMPLETED IN ALL CASES / A REMPLlR DANS TOUS LES CAS
NGmero de Seguro social de Canadd
Canadian Social Insurance Number
NumBro d assurance sociale du Canada
1
DATOS PERSONALES DEL ASEGURADO Y DE su CONYUGE
PERSONAL INFORMATION REGARDING THE INSURED AND HIS/ HER SPOUSE
RENSEIGNEMENTS PERSONNELS CONCERNANT LA PERSONNE A S S U R ~ EET SON CONJOINT
Del solicitante (2)
Claimant (2)
Du dernandeur (2)
1.1.
Apellldos (4)
Sumames (4)
Norns de farnille (4)
1.2.
Apellldos de soltera
Maiden name
Norn de jeune fille
1.3.
Nombre
First name
Prknorn
Del c6nyuge (3)
Spouse (3)
Du conjoint (3)
1
Del sollcitante (2)
Claimant (2)
Du demandeur (2)
1.4. Nombre de 10s padres
Name of parents
Nom des parents
1.5. Dlreccl6n (5)
Address (5)
Adresse (5)
1.6. Fecha de naclmlento
Date of birth
Date de naissance
1.7. Sex0
Sex
Sexe
1.a. Naclonalldad
Citizenship
Nationalit6
1.9.
D. N. I. (6)
Number of ldenffty Card (6)
No. de carte d'identitb (6)
1.lO.No. de aflllacl6n a la Segurldad Social espaftola
Spanish Social Security number
No. d'affillation B la Sbcuritb Soclale espagnole
1.11.Estado clvil (7')
Marital status (7)
Etat civil (7)
1.12.Fecha de matrimonlo
Date of marriage
Date de mariage
1.13.Fecha de falleclmlento
Date of death
Date du d b d s
1.14.Causa del falleclmlento (8)
Cause of death (8)
Cause du decks (8)
1.15. jSe considera el lnteresado lncapacitado para el trabajo?
Does the daimant consider himlherself unfit for work?
L'lntBressQ(e) se considhre-t-il (elle) inapte au travail?
1.16.~Reallzaactlvldad laboral?
Is he/she working at present?
Travaille-1-11(elle) encore?
1.17.~Esthacogldo a Convenlo Especial?
Does claimant belong to a special plan
(voluntary insurance)?
BQnbficie-1-11(elle) d'une convention spbcialel
assurance volontaire?
1.lB.Fecha en que ha dejado de trabajar
Date on which employment ceased
Date d'arret de travail
1.1O.Fecha en que se propone cesar
Date on which employment is expected to k a s e
Date pdvue d'arret de travail
1.20.~Percibealguna prestaclbn? (9)
Is any benefit paid? (9)
Une prestation est-elle versbe? (9)
1.21 .LHa perclbldo alguna prestacl6n?
Has any benefit been paid?
Une prestation a-1-elle 616 vers&?
Del c6nyuge (3)
Spouse (3
DU conjo~nt
(3)
Del solicitante (2)
Claimant (2)
Du demandeur (2)
1.22.
Del conyuge (3)
Spouse (3
Du conjo~nt
(3)
SI uno de 10s puntos 1.20 o 1.21., es aflrmatlvo, lndlcar
if either 1.20 or 1.21. is a m a t i v e please state:
Dans I'afflrrnative a 1.20 ou 1.21., indiquer:
Clase de pensl6n
Type of pension
Le type de pension
Organlsmo que la satisface
Institution responsible for payment
L'organisme responsable du paiement
lmporte mensuel (10)
Monthly benefit (10)
Le montant mensuel (10)
Fecha de efectos
Date on which pension became payable
La date du debut des paiements
Feche do venclmlento
Date on Mich pension ceased or is expected to cease
La date de cessation des paiements
1.23.
2
Otros recursos
Other resources
Autres ressources connues
A CUMPLIMENTAR I~NICAMENTE EN EL SUPUESTO DE SOLlClTUD DE PENSION DE INVALIDEZ
TO BE COMPLETED ONLY WHEN CLAIMING A DISABILlN PENSION
A REMPLIR UNIQUEMENT EN CAS D'UNE DEMANDE DE PENSION D'INVALIDIT~
ORIGEN DE LA INVALIDEZ I CAUSE OF DISABILIN 1 CAUSE DE L'INVALIDIT~
Enfermedad comun
Common illness
Maladie commune
[7
Enfennedad profeslonal
Occupational disease
Maladie professionnelle
Accldente de trabajo
industrial accident
Accident du travail
Accldente no laboral
Non-industrial accident
Accident non pmfesslonnel
HlJOS I CHILDREN I ENFANTS
Apellldos y nombre
Fecha de nacimlento
Sumames and First Name
Date of bltih
Norns et Pr6noms
Date de naissance
~Estd
Incapacltado
para el
trabajo?
Is he/she
unfff lor
emp/opent?
Est-ll(elle)
lnapte au
travall?
L E penslonlsta
~
o tltular
de re,,tn?
Is he/she a
pensioner w
recipient of
a penodrc
benefit?
Est-ll(elle)
retralt6(e)ou
t~tulaire
dune renle?
~Obtlene
OtmYJ Ingm=3?
he/she
Ofher
Income7
Re@t-ll(elle)
d'autres
revenus?
7
4
DECLARACION DE ACTIVIDADES DEL ASEGURADO EN E S P A ~ A
EMPLOYMENT HISTORY OF THE INSURED IN SPAIN
EMPLOIS PRECEDENTSDE L'ASSURE(E) EN ESPAGNE
Nornbre y dlrecci6n de la Ernpresa
Name and address of employer
Nom et adresse de I'employeur
5
Provlncia
Province
Province
Periodo 1 Period 1 Pdriode
desde 1 from 1 de
haste Ito 1 8
PER~ODOSTRABAJADOS EN OTROS PA~SES
PERIODS O F WORK IN OTHER COUNTRIES
PERIODES TRAVAILLEES DANS D'AUTRES PAYS
No.de asegurado o, en s u defecto, nombre
de la Empresa, trabajos corno autbnorno, etc.
Social Security Number or name of the
enterprise, work as self-employed person, etc.
No.d'assurd ou, sinon, nom de I'Entreprise,
activitds exerches en tant que le
travailleur independant, etc.
Periodo (a Aos)
Desde
Localldad
City
Localit6
Pais
Country
Pays
Hasta
Period (years)
From
To
Pdriode (ann6es)
De
A
Declaro, bajo ml responsabilidad, que son ciertos 10s datos que conslgno en el presente formulario.
Asimismo, manlfiesto que quedo enterado de la obligaclon de comunlcar al lnstltuto Naclonal de Seguridad
Social cualquier varlacion en 10s datos declarados que pueda producirse en lo sucesivo.
1 hereby declare that the information provided in this form is true and accurate.
I further acknowledge that I am required to notify the INSS of any change in this information which may occur in
future.
Je declare, sous ma responsabilite, que les reinseignernents que je fournis dans la presente forrnule sont vrais.
De meme, je declare que je suis tenu de communiquer B I'lnstitut National de la S6curitB Sociale tout changernent
relatif aux renseignements declares qui pounait intervenir dans I'avenir.
(A CUMPLIMENTAR S ~ L O
EN CASO DE SOUCrrUO DE PRESTACIONES DE SUPERVNENCIA)
(TO BE COMPLETED ONLY IN CASE OFA CLAIM FOR A SURVIVOR'SPENSION)
(A NE REMPLIR QU'EN CAS D'UNE DEMANDE DE PRESTATIONS DE SURVIVANT)
Declaro, bajo ml responsabilidad, que convlvfa con:
I declare, under my responsibility, that I lived with:
............................................................................................
Je declare sur I'honneur, que je vivais avec:
en el siguiente domlclllo: .....................................................................................................................................
at the following address:
B l'adresse suivante:
...................................................................................................................................
.....................................................................................................................................
desde
from
d~
1
I
Die
Day
Jour
I
I
Mes
Month
Mois
AAo
Year
Ann&
hasta
f0
a~
I
I
Die
Day
Jour
I
I
Mes
Month
Mois
AAo
Year
Ann&
Autorlzo a la Institucl6n de Canad6 a facllltar al lnstituto ~ a c i o n ade
l Seguridad Soclal de Espafia, toda la
lnformacion y pruebas que posea, relacionados o posiblemente relacionados con esta solicitud de prestaciones.
I authorize the Canadian institution to provide the INSS with any information or evidence it may have which
relates, or which might relate to the present claim for benefits.
J'autorise I'organisme canadien B fournir B I'lnstitut National de Sdcurite Sociale dlEspagne tous les
renseignernents et preuves qu'il detient, et qui sont ou peuvent &re relatifs B la pr6sente dernande de
prestations.
Firma del sollcltante,
Claimant's signature,
Signature du demandeur,
A CUMPLIMENTAR POR LA INSTITUC~ON
CANADIENSE
TO BE COMPLETED BY THE CANADIAN INSTITUTION
A REMPLIR PAR L'ORGANISME CANADIEN
Se hace constar que 10s datos personales vidados en este formularlo han sldo debidamente comprobados por
esta Instltucion.
This certifies that the personal information supplied in this form has been duly verified by this Institution.
Ceci certifie que les renseignements personnels fournis dans la presente formule ont Bt6 dOment verifies par
I'organisme.
Sello
Stamp
Timbre
Fecha
Da fe ................................................................................Date
Flrma
Signature
Signature
.......... ..................... .......................................... ..
NOTAS / NOTES / NOTES
Marquese lo que proceda
Mark whichever is applicable
Cocher la case appropriee
En las solicitudes de vejez e invalldez: 10s datos del prop10 Interesado. En las de viudedad, 10s
correspondientes a la viudalo. En las de orfandad: 10s correspondientes a la viudalo o en su defect0 el
representante legal de 10s huBrfanos.
If old age or disability benefits are being claimed, provide information in this column regarding the insured
person
If widow's/widower's benefits are being claimed, provide information in this column regarding
the widowhidower. If orphans' benefits are being claimed, provide-information in this column regarding
the widow/widower or, if there is none, regarding the legal representative of the orphaned child.
Pour les demandes de prestations de vieillesse ou d'invalidite, donner les details concemant la personne
assuree. Pour les demandes de pension de veuf (veuve), donner les details concernant le veuf/veuve.Pour
les demandes de prestations d'orphelin, donner les details concernant le veuflveuve ou, s'il n'y en a pas, le
representant legal de I'orphelin.
.
En las sollcitudes de vejez e invalidez: 10s datos del c6nyuge del asegurado. En las de supewlvencia: 10s
del asegurado fallecido.
If old age or disability benefits are being claimed, provide information in this column regarding the spouse
o t i h e insured person. If survivors' benefits are being claimed, provide information in this column about the
deceased insured person.
Pour les demandes de prestations de vieillesse et d'invalidite, indiquer les donnees concemant le conjoint
de la personne assuree. Pour les demandes de pension de survivant, indiquer les donnees concemant la
personne assure6 de&d6e.
Para naclonales espafioles, conslgnar 10s dos apellldos.
For Spanish nationals, list both surnames.
Pour les ressortissants espagnols, indiquer les deux noms de famille.
NLirnero, calle, localidad, distrito postal, pais.
Number, street, town, postal code, country.
Numero, rue, vilie, code postal, pays.
- .-
.
-
Para naclonales espaiioles, indicar el numero del Documento Naclonal de ldentidad (D. N. I.), aunque estB
caducado. Si no l o posee, indicar expresamente: "no tiene".
For Spanish nationals, enter identity card (DNI) number even if expired. If claimant does not have a DNI
number, enter the words "no identity card':
Pour les ressortissants espagnols, indiquer le numero de la carte d'identite (D.N.I.) meme s'il n'est pas
valable. S'il (elle) n'en a pas, indiquer "pas de carte d'identite".
lndlcar de entre Bstos el que proceda: soltero, casado, separado, divorclado, viudo y, a contlnuaclbn,
desde cuando.
State whether single, manied, separated, divorced or widowed (give date of separation or divorce, or date
of spouse's death).
lndiquer si la personne assuree est celibataire, mariee, separee, divorcee ou veuve 1 veuf (donner la date
du divorce ou du decbs du conjoint).
lndlcar lo que proceda: accidente de trabajo, enfermedad profeslonal, accldente no laboral, enfermedad
comun.
State cause of death : industrial accident, occupational disease, non-industrial accident or common illness.
lndiquer la cause du decbs: accident du travail, maladie professionnelle, accident non professionnel ou
maladie commune.
Desempleo, lncapacldad laboral transitoria, invalidez provisional, etc.
Unemployment, temporary incapacity, provisional disability, etc.
Chamage, invalidit6 temporaire, invalidit6 provisoire, etc.
Pesetas o dolares canadienses.
Indicate whether figure is in pesetas or Canadian dollars.
lndiquer si le montant est en pesetas ou dollars canadiens.
DOCUlVLENTOS QUE DEBE PRESENTAR CON ESTA SOLICITUD
DOCUMENTS TO BE SUBMITTED WITH THIS CLtUM
DOCUMENTS QUE vous DEVEZ PRESENTER AVEC LA DEMANDE
a)
Solicltud de pensl6n de vejez:
Application for old age pension:
Dernande de pension de vieillesse:
Documento Naclonal de ldentldad o Certlflcacl6n de Naclmlento.
National ldentify Card or Birth certificate.
Carte d'ldentit6 Nationale ou certificat de nalssance.
Si realizd trabajos en el sector maritimo pesquero en Espaiia, aportah la libreta de Navegacidn espaflola y , en su caso, tambien la
de 10s demhs paises donde haya realizado tal clase de actividad, o cualquier tip0 de docurnentacidn (certificados de ernpresa, de la
Autoridad de Marina, etc ...) que acredite dichas circunstancias.
If the insured person performed a professional activity in the merchant marine or fishlng industry in Spain, he / she should provlde
the Spanish Navigation booklet and, where applicable, the booklets of other countries where such activity was performed, or any
kind of documentary evidence ( certifica- tes Issued by a company, marine authorify, etc.) cerliwng such activities.
SI des activites de pbche maritime ont 616 kalisees en Espagne, presenter le livret de Navigation espagnole, alnsl que celul des
autres pays oi, ce type d-activit6 aurait 6te eventuellement realis6 ou toute autre documentation (certificat d'entreprise, de I'
autorite maritlme, etc.) le certifiant.
-
-
b)
-
Sollcltud de pensi6n de Invaiidez:
Application for disability pension:
Dernande de pension d'invalidite:
Documento Naclonal de ldentldad o Certlflcacldn de Naclmlento.
National ldentity Card or Birth certificate.
Carte d'ldentit6 Nationale ou certificat de naissance.
Documentaclon medlca.
Medical documents.
Cerlificat rn6dical.
Si realizd trabajos en el sector marltimo pesquero en Espaiia, aportad la llbreta de Navegacidn espaflola y , en su caso, tambien la
de 10s demhs paises donde haya reaiizado tal clase de actividad, o cualquier tip0 de docurnentacidn (certificados de ernpresa, de la
Autoridad de Marina, etc...) que acredite dichas clrcunstanclas.
If the insured person performed a professional activity in the merchant marine or fishlng industry in Spain, he / she should provide
the Spanish Navigation booklet and, where applicable, the booklets of other countries where such activify was perfonned, or any
kind of documentary evidence ( certifica- tes issued by a company, marine authority, etc.) certifyingsuch activities.
Si des activites de phche maritime ont Btd realisees en Espagne, presenter le livret de Navigation espagnole, alnsl que celui de?
autres pays oh ce type d'activitd aurait Qt6 Bventuellement realist5 ou toute autre documentation (certificat d'entreprise, de I
autorite maritime, etc.) le certifiant.
-
-
-
c)
-
Sollcitud de prestacldn por muerte y supervlvencia:
Application for sunriwr's benefits:
Demande de prestations de su~ivants:
Si realizd trabajos en el sector marftlmo - pesquero en Espafla, aportad la libreta de Navegacldn espaflola y , en su caso, tamblen la
de ios dernhs paises donde haya reallzado tal clase de actividad, o cualquier tipo de docurnentacidn (certificados de empresa, de la
Autoridad de Marina, etc...) que acredite dichas circunstancias.
I f the insured person performed a professional activity in the merchant marine or fishing industry In Spain, he /she should provide
the Spanish Navigation booklet and, where applicable, the booklets of other countries where such activity was performed, or any
kind of documentaryevidence ( cerfifica- tes issued by a company, marine authority, etc.) certifjing such activities.
Si des activites de peche maritime ont 616 kalisbes en Espagne, presenter le livret de Navigation espagnole, alnsl que celui des
autres pays oi, ce type d'activltd aurait Bt6 eventuellement reallse ou toute autre documentation (certificat d'entreprise, de I'
autorite maritlme, etc.) le certifiant.
-
caso 1 In all cases / Dans tous les cas:
-En todo
Certificacidn de defunclon, en la que se haga constar l a causa del falleclmlento.
Death certificate stating cause of death.
Certificat de d6&s, avec mention de la cause du d6chs.
Pensldn de vludedad:
S u ~ ' v i n spouse's
g
penslon:
Pension de veuf (veuve):
Documento Naclonal de Identidad o Certlficacldn de naclmlento de la vludehrludo.
National ldentify Card or Blrth certificate of the widowhvidower.
Carte d'ldentitb Nationale ou certificat de naissance de la veuveheuf.
Llbro de Famllla o, en su defecto, certlflcaclon de matrlmonlo.
Family Register of Vital Statistics or marriage certificate.
Livret de farnille ou certificat de mariage.
En caso de exlstlr separacldn legal o dlvorclo, fotocopla de la sentencla flrme en que se acredite. SI n o hublera sentencia flnne,
fotocopla del documento que justiflque haber lnlclado el expediente de separacldn matrlmonlal o de dlvorclo.
In the case of legal separation or divorce, attach a copy of the final decree or proof that separation or divorce proceedings have
been initiated.
En cas de separation legale ou de divorce, annexer une cople de la decision du' tribunal. S'il n'exlste aucune d6clsion, annexer
une copie du document justiflant que la procedure de separation maritale ou de divorce a 616 entambe.
-
Pensldn de orfandad:
Olphan's pension:
d'orphelin:
-Pension
Llbro de famllla o, en su defecto, Documento Naclonal de ldentldad o Certlflcacldn de naclmlento de 10s hljos por 10s que
sollclta pensldn (menores de 18 aiios o mayores Incapacltados). De exlstlr hljos adoptlvos, documentos que acrediten la
adopcidn legal.
Family Register of Vital Statistics, National ldentity Card or Birfh certificates of children for whom benefits are being claimed
(disabled adults or minor children under 18). In case of adopted children, provide proof of legal adoption.
Livret de famille, Carte d'ldentitb Nationale ou certificat de naissance des enfants pour lesquels une penslon est demandbe
(enfants de rnoins de 18 ans ou plus, s'ils sont incapables de travailler). En cas d'enfants adoptes , documents certifiant
I'adoption i6gale.
Canada / Spanish Agreement
Documents and/or information required to support your application [CAN-E 1]
for a Spanish Death and/or Survivor’s Benefit
Complete the attached forms:
•
Canadian Residence [SC ISP5015] (only if the deceased was in receipt of a Canadian Old Age
Security pension)
•
Additional Page to form CAN-E 1 (only if you someone other than the surviving spouse)
Original or certified documents to be submitted:
•
Birth certificate or National Identity Card (D.N.I.) for you, the deceased and any children
•
Marriage certificate or family register
•
Death certificate that states cause of death
•
Decree or judgment of divorce (if applicable)
•
Spanish Navigation booklet or documentary evidence certifying such activity (only if the deceased
performed professional activity in the merchant marine or fishing industry)
•
Proof of the dates of your entry(ies) to Canada and departure(s) from Canada (such as:
Immigration 1000, passport, visa, ship or airline tickets, etc.) (only if the deceased was in receipt of
a Canadian Old Age Security pension)
Information required:
• Your Spanish National Identity Card (D.N.I.) Number: ____________________
• Your Spanish Social Security Registration Number: ____________________
IMPORTANT: If you have already submitted any of the documents required when you applied
for a Canada Pension Plan or Old Age Security benefit, you do not need to
resubmit them.
Service
Canada
CANADIAN RESIDENCE - INFORMATION REGARDING
A DECEASED PERSON
Protected when completed - B
Personal Information Bank
HRSDC PPU 175
Canadian Social Insurance Number
Mr.
Mrs.
Ms.
Miss First Name and Initial
Last Name
The following information is required to support your application for benefits under a social security agreement.
If required, please provide additional information on a separate sheet of paper.
1. If the deceased was born outside of Canada, please provide us with the following information:
• Date of arrival in Canada:
• Place of arrival in Canada:
2. List all the places where the deceased lived in Canada after the age of 18 and provide proof of all his/her dates of
entry and departure (immigration 1000, complete passport, airline tickets, etc.):
From
(Year/Month/Day)
To
(Year/Month/Day)
City
Province/Territory
3. List all absences from Canada, which were longer than six months, during his/her Canadian residence listed in
number 2 above:
Departure
(Year/Month/Day)
Destination
Return
(Year/Month/Day)
Reason
4. Please give us the names, addresses and telephone numbers of at least two people, not related to you or the
deceased by blood or marriage, who can confirm his/her Canadian residence:
Name
Address
Telephone Number
City
(
)
-
(
)
-
DECLARATION OF APPLICANT
I declare that this information is true and complete. (It is an offence to make a misleading statement)
Signature:
X
Telephone number:
Date:
(
)
-
Year
Service Canada delivers Human Resources and Skills Development Canada
programs and services for the Government of Canada.
SC ISP5015 (2011-03-01) E
Month
Day
HOJA A INTERCALAR AL FORMULARIO CAN - E 1
ADDITIONAL PAGE TO FORM CAN - E 1
FEUILLE ADDITIONNELLE A LA FORMULE CAN - E 1
A
A CUMPLIMENTAR UNICAMENTE SI SE SOLICITA PRESTACION EN FAVOR DE FAMILIARES (1)
TO BE COMPLETED ONLY WHEN CLAIMING BENEFITS FOR FAMILY MEMBERS ( 1 )
REMPLIR SEULEMENT EN CAS DE DEMANDE DE PRESTATIONS EN FAVEUR DES MEMBRES DE LA FAMILLE (1)
El familiar que solicite la prestacion en Favor de Familiares, debera cumplimentar el apartado 1 "Datos
personales del asegurado y de s u conyuge" del formulario CAN E 1, indicando los datos propios en la
columna relativa al "solicitante" y 10s datos de la persona fallecida en la columna relativa al "conyuge".
The relative claiming benefits on behalf of members of hidher own family must complete Pail I of form
CAN - E I ("Personal information regarding the insured and hidher spouse'^, listing his or her personal
information under the column entitled "Claimant" and providing information on the deceased in the column
entitled "Spouse':
Le parent qui demande une prestation en faveur des rnembres de la farnille doit rernplir la Partie 1.
"Renseignements personnels concernant la personne assuree et son conjoint", du formulaire CAN - E 1, en
indiquant les donnees appropriees dans la colonne correspondante au "Demandeur" et les donnees
concernant la personne decedee dans la colonne correspondante au "Conjoint".
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Otros datos del familiar que solicita la prestacion:
Additional information on the relative claiming benefits on behalf of family members:
Autres renseignements sur le parent qui dernande une prestation:
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Parentesco con el fallecido
Relationship to the deceased
Lien de parent6 avec la personne decedee .............................................................................................
~ C o n v i v i acon la persona fallecida?
Did he/she live with the deceased?
Vivait-il (elle) avec la personne decedee? ...............................................................................................
~Dependia
economicamente de la persona fallecida?
Did he/she depend on the deceased for financial support?
.................................................................
Dependait-il (elle) financierement sur la personne decedee?
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DOCUMENTAC~ONQUE DEBE PRESENTAR IDOCUMENTS TO BE SUBMI77ED /DOCUMENTS A PR~SENTER
EN TODO CASO / INALL CASES/DANS TOUS LES CAS
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Documento Nacional de Identidad.
National Identity Card.
Carte d'ldentite Nationale.
Certificacion de defuncion, en la que se haga constar la causa del fallecimiento.
Death certificate stating cause of death.
Certificat de deces, avec mention de la cause du ddces.
Libro de familia o Certificaciones de las actas que acrediten el parentesco del solicitante con el
fallecido.
Family Register of Vital Statistics or certified documents proving relationship to the deceased.
Livret de famille ou certificats indiquant le lien de parente, avec la personne decedee, de la personne
qu~
presente la dernande.
SI EL SOLICITANTE ERA NIETOIA, HERMANOIA, ABUELOIA DEL FALLECIDO:
IF THE CLAIMANT WAS A GRANDCHILD, BROTHER/SISTER, GRANDPARENT OF THE DECEASED:
SI LE DEMANDEUR ETAITUN PETIT-ENFANT, UN FREREISOEUROU UN GRAND-PARENTDELAPERSONNE
DECEDEE:
Certificado de Defuncion del padre.
Death certificate of the father.
Certificat de deces du pere.
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(1)
( 1)
(1)
Nietos, hermanos, padres, abuelos, hijas que reunan determinados requisitos de edad, estado civil,
convivencia, falta de medios, etc., segljn el caso.
Grandchildren, brothers, sisters, parents, grandparents and daughters that fulfil certain conditions of
age, civil status, cohabitation, lack of means, etc., as the case may be.
Les petits-enfants, les freres, les soeurs, les parents, les grands-parents, les filles qui rernplissent
certaines conditions d'dge, d'etat civil, de cohabitation, de manque de rnoyens, etc., selon le cas.