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_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Office of the Vulnerable Persons’ Commissioner
Application for the Appointment of aSubstitute Decision
Maker
Under The Vulnerable Persons Living with a Mental Disability A
t, certain requirements must be metin order for a substitute
decision maker to be appointed for an individual. T ese
requirements are addressed by t e questions asked in t is
application form. Please answer all questions in as muc detail as
possible.
Please refer to t e Guide to Completing the Substitute De ision
Maker Application for furt er explanation and direction in
completing t is application.
If you need more space to complete your answers, please attac a
separate page and include t e section numbers (ex: 1.2, A, i).
Ce formulaire de demande e iste également en français. Composez
le 204-945-5039 ou le 1 800 757-9857(sans frais).
Part 1 InformatIon about the Person for Whom a substItute
DecIsIon maker Is requesteD – calleD “the InDI IDual” In thIs
aPPlIcatIon
1.1 About the individual
_____________________________________________________________________________________________
_____________________________________________________________________________________________
Last name First name Middle name
Birth date (mm/dd/yyyy) Gender
______________________________________________________________________
o M o F
Address (street number, street name, town/city, province, postal
code)
Mailing address, if different from above (street number, street
name, town/city, province, postal code)
Type of residence (family ome, community residence, foster ome,
independent Living there since? living wit support, personal care
ome, developmental centre, etc.)
Who is the main contact person at the residence? Name Title P
one number
( )
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_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
List ways in which the individual is involved in the community
(day programs/work/sc ool)
1. Name of program/work/sc ool:
Main contact person at t e program/work/sc ool (name, title, p
one number)
Attending since?
2. Name of program/work/sc ool:
Main contact person at t e program/work/sc ool (name, title, p
one number)
Attending since?
3. Name of program/work/sc ool:
Main contact person at t e program/work/sc ool (name, title, p
one number)
Attending since?
1.2 Is the individual a vulnerable person? (See under Se tion C
– part 1, subse tion 1.2 of guide)
a) An adult living ith a mental disability (“Mental disability”
excludes a mental disability due exclusively to a mental or psyc
iatric disorder defned under The Mental Health A t.)
The following are the criteria that defne “mental disability”. E
plain why you believe the individual is:
i) a person with Signifcant Intellectual Impairment
ii) a person with Impaired Adaptive Behaviour
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_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
__________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_______________
iii) a person with a disability Manifested Prior to Age 18
b) Assistance meeting basic needs Describe what kind of
assistance the individual needs to meet his or her basic needs
for:
Personal care (ex: elp wit medical issues, personal ygiene,
domestic tasks, etc.)
Property (ex: elp wit money management)
1.3 Supporting documents (See under Se tion C – part 1, subse
tion 1.3 of guide)
Attach documents to support the information provided in
questions 1.2 and 6.1.E amples of supporting documents include:
evaluation report(s) from psychologists, psychiatrists,
pediatricians, school clinicians (speech pathologists,occupational
therapists), etc. medical records diagnosing a specifc
developmental disorder, signifcant cognitive impairment or mental
disability supported living level of care form supported living
personal fnancial plan individual plan (IP) or individual education
plan (IEP) behaviour support plan and/or other related information
e isting social history reports other
Vulnerable Persons’ Commissioners’ Offce (VPCO) use only
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______________________________________________________
______________________________________
______________________________________________________________________________________________
______________________________________________________
______________________________________
______________________________________________________________________________________________
1.4 Individual’s social orker/case co-ordinator (if kno n)
Name
__________________________________________________________________________
Mailing address
___________________________________________________________________
( ) ( )P one number ___________________________________
Fax_____________________________
1.5 Individual’s nearest relative (See under Se tion C – part 1,
subse tion 1.5 of guide)
Name Relations ip to individual
Mailing address
( )P one number
________________________________________________________________________________
Part 2 InformatIon about the aPPlIcant
Name Relations ip to individual
Mailing address
P one number
________________________________________________________________________________(
)
Part 3 reason(s) for the aPPlIcatIon (See under Se tion C – part
3 of guide)
3.1 What are the circumstances that give you reason to believe
that a substitutedecision maker is needed at this time?
Part 4 InformatIon about the InDI IDual’s suPPort netWork (See
under Se tion C – part 4 of guide)
4.1 People ho provide advice, support and guidance to the
individual
a) Family members 1. Name
_____________________________________________________________________________________
Mailing address
_____________________________________________________________________________
P one number _______________________________ Relations
ip___________________________________ ( )
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___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
Nature and frequency of involvement
__________________________________________________________
2. Name
_____________________________________________________________________________________
Mailing address
_____________________________________________________________________________
( )P one number _______________________________ Relations
ip___________________________________
Nature and frequency of involvement
__________________________________________________________
3. Name
_____________________________________________________________________________________
Mailing address
_____________________________________________________________________________
( )P one number _______________________________ Relations
ip___________________________________
Nature and frequency of involvement
__________________________________________________________
4. Name
_____________________________________________________________________________________
Mailing address
_____________________________________________________________________________
( )P one number _______________________________ Relations
ip___________________________________
Nature and frequency of involvement
__________________________________________________________
b) Others chosen by the individual (friends, paid service/care
providers, advocates, etc.)
1. Name
_____________________________________________________________________________________
Mailing address
_____________________________________________________________________________
P one number _______________________________ Relations
ip___________________________________ ( )
Nature and frequency of involvement
__________________________________________________________
2. Name
_____________________________________________________________________________________
Mailing address
_____________________________________________________________________________
P one number _______________________________ Relations
ip___________________________________ ( )
Nature and frequency of involvement
__________________________________________________________
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____________________________________________________________________________________________
____________________________________________________________________________________________
___________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
3. Name
_____________________________________________________________________________________
Mailing address
_____________________________________________________________________________
( )P one number _______________________________ Relations
ip___________________________________
Nature and frequency of involvement
__________________________________________________________
1. Name Relations ip P one number
( )
Mailing address
2. Name Relations ip P one number ( )
Mailing address
4.2 Service/care provider (if not mentioned above)
Part 5 InformatIon about the ProPoseD substItute DecIsIon
maker(s) (sDm) (See under Se tion C – part 5 of guide)
5.1 Sole substitute decision maker(s) (SDM)
1. Name Relations ip
______________________________________________________________________
___________________
Mailing address P one number
(
)______________________________________________________________________
___________________
SDM forPersonal care Property
______________________________________________________________________
2. Name Relations ip
______________________________________________________________________
___________________
Mailing address P one number
(
)______________________________________________________________________
___________________ SDM forPersonal care Property
______________________________________________________________________
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____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
5.2 Joint substitute decision maker(s) (SDM)
______________________________________________________________________
______________________________________________________________________
____________________________________________________________________________________________
______________________________________________________________________
1. Name Relations ip
Mailing address P one number
( )
SDM forPersonal care Property
2. Name Relations ip
Mailing address P one number
( )
SDM forPersonal care Property
3. Name Relations ip
Mailing address P one number
( )
SDM forPersonal care Property
5.3 Alternate substitute decision maker(s) (ASDM)
______________________________________________________________________
______________________________________________________________________
1. Name Relations ip
Mailing address P one number
( )
ASDM forPersonal care Property
2. Name Relations ip
Mailing address P one number
( )
ASDM forPersonal care Property
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_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Notes: • “Sc edule A” must be completed if applying to be a
substitute decision maker for property. • “Sc edule B” must be
completed by all proposed substitute decision makers. • A Criminal
Record C eck, C ild Abuse Registry C eck, and an Adult Abuse
Registry C eck is required by all
proposed substitute decision makers – see “Sc edule C” • If a
substitute decision maker is not identifed, T e Public Trustee will
be appointed.
Part 6 DecIsIon(s) to be maDe (Appli ants should read under Se
tion C – part 6 of guide before ompleting this se tion)
6.1 Decision(s) to be made
Describe below the decision(s) or issue(s) the individual:
• is facing now and/or e pected to face in the reasonably
foreseeable futureAND
• is not able to make even with the involvement of his or her
support network
A person is considered unable to make a decision w en s e/ e is
not able to understand information relevant to making a decision
about personal care or t e management of property; or is not able
to appreciate t e reasonably foreseeable consequences of a decision
or lack of one.
What decision(s) or issue(s) is/are there in the area of
personal care?
What decision(s) or issue(s) is/are there in the area of
property?
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____________________________________________________________________________________
______
____________________________________________________________________________________
______
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
______________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________
_________________________________
Part 7 other InformatIon requIreD
7.1 Considering the decision(s) to be made in Part 6, what
should be the length of time of the substitute decision maker
appointment? (See under Se tion C – part 7, subse tion 7.1 of
guide)
7.2 Is there currently a substitute decision maker appointed for
the individual? Yes No
Has there been in the past? Yes No
7.3 Does the individual have a committee appointed by the Court
of Queen’s Bench or an Order of Committeeship under The Mental
Health Act? (See under Se tion C – part 7, subse tion 7.3 of
guide)
Yes No
7.4 Describe any physical or communication arrangements that
will be needed for the individual,the proposed substitute decision
maker and/or other parties should they need to participate at a
hearing panel. (See under Se tion C – part 7, subse tion 7.4 of
guide)
7.5 Do you have further information or comments that would be
helpful to the commissioner in considering this application for
appointment of a substitute decision maker?
sIgnature of aPPlIcant
Signature Date
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Have you: completed t e application in full
enclosed supporting documents noted on page 3
completed “Sc edule A” – real and personal property (if applying
for property)
completed “Sc edule B” – consent form signed by t e proposed
substitute decision maker(s)
enclosed t e Criminal Record C eck(s), C ild Abuse Registry C
eck(s), and AdultAbuse Registry C eck for all proposed substitute
decision makers – See “Sc edule C”
Note: Incomplete application packages will take longer to
process.
Send completed applications and documents to: Office of the
Vulnerable Persons’ Commissioner 315-258 Portage Avenue Winnipeg,
Manitoba R3C 0B6
Telephone: 204-945-5039 Toll Free: 1-800-757-9857 Fax:
204-948-3713
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__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
____________________________________________
_________________________________
for communIty ser Ice Worker/socIal Worker use only
For VPCO information gathering purposes, if you directly
assisted the applicant in completing this application, please
complete the following:
1) Do you believe a substitute decision maker is warranted for
this individual?Yes No
Why?
2) Do you believe the proposed substitute decision maker(s) is
suitable, capable and able to perform the duties of a substitute
decision maker? Yes No
Why?
3) Do you have further information or comments that would be
helpful to the commissioner in this application for appointment of
a substitute decision maker?
sIgnature of csW/socIal Worker
Signature of CSW/Social Worker Date
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_______________________________________________________________________
_______________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
___________________________________________________________________________
SCHEDULE A REAL AND PERSONAL PROPERTY (IF KNOWN)
OF [person for whom application is made]
__________________________________________
1. REAL AND PERSONAL PROPERTY
Bank/Investment accounts [place of deposit, balance of each
account]:
Stocks and bonds [estimate of value, place of deposit]:
R.R.S.Ps [amount, place of deposit]:
Real estate [legal descriptions of civic addresses]:
Vehicles [make, model, year]:
Life insurance policies [cash surrender values, names of
insurers]:
Funeral plans [cash value, place of deposit]:
Monies owed to [estimate of amounts, names of debtors]
Other (specify)
2. DEBTS: Liability: Personal/Property loans
Creditor ________________________ Balance owing
_______________________
Liability: Credit cards
Creditor ________________________ Balance owing
_______________________
Liability: Other (specify)
Creditor ________________________ Balance owing
_______________________
http:R.R.S.Ps
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___________________________________
______________________________
3. INCOME:
Source _____________________ Amount ___________ Frequency
_______________
Source _____________________ Amount ___________ Frequency
_______________
4. EXPENSES:
Source _____________________ Amount ___________ Frequency
_______________
Source _____________________ Amount ___________ Frequency
_______________
Signature Date
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SCHEDULE B
Consent Form for Considerationof Appointment as Substitute
Decision Maker
I/We, [name(s) of proposed substitute decision maker(s)]
do hereby consent to my/our appointment as substitute decision
maker(s) for
[name of person for whom substitute decision maker is
requested]
in respect of whom decision-making power is sought in the areas
of o personal careo property
I/We understand that my/our appointment as a substitute decision
maker is conditional upon the results of a Criminal Record Check
(including the Vulnerable Sector Search), a Child Abuse Registry
Check and an Adult Abuse Registry Check and agree to apply for
these checks and to submit these records to the Vulnerable Persons’
Commissioner.
I/We understand that my/our appointment will require me/us to
comply with the duties of a substitute decision maker as set out in
The Vulnerable Persons Living with a Mental Disability Act and any
terms and conditions as directed by the Vulnerable Persons’
Commissioner.
I/We further understand that as a substitute decision maker for
property I/we will be required to file within six months of my/our
appointment a true inventory and account of the vulnerable person’s
property, debts and liabilities which would be under my/our power,
and yearly thereafter, an annual accounting of the property, debts,
liabilities, receipts and disbursements of the vulnerable person,
unless I am/we are directed otherwise by the Vulnerable Persons’
Commissioner.
I/We further understand that as a substitute decision maker for
property I/we may be required to provide a bond or other security
which would be equal to the amount of the sworn value of the
property under my/our power as the substitute decision maker(s), as
directed by the Vulnerable Persons’ Commissioner.
*Signature of proposed substitute decision maker Date
*Signature of proposed substitute decision maker Date
* Not required for The Public Trustee
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SCHEDULE C
CRIMINAL RECORD, CHILD ABUSE REGISTRY AND ADULT ABUSE REGISTRY
CHECKS
As part of the Application for Appointment of a Substitute
Decision Maker, a proposed substitute decision maker must obtain a
Criminal Record Check, a Child Abuse Registry Check, and an Adult
Abuse Registry Check. The results of these Checks will be sent to
you directly. It is your responsibility to then attach them to the
Application and/or to send them to the Office of the Vulnerable
Persons’ Commissioner.
CRIMINAL RECORD CHECK
A Criminal Record Search Certificate can be obtained from the
local city or municipal police department, or in rural areas, from
the local Royal Canadian Mounted Police detachment. The Criminal
Record Check must include the Vulnerable Sectors Search. When
returning the completed form to the police/RCMP, two pieces of
identification and an associated fee payment is normally required.
The police office will provide the Criminal Record results to you.
Questions regarding this process should be directed to your local
city, or municipal police department or local RCMP detachment
(rural areas only). For Winnipeg residents, information can be
obtained by calling 204-986-6074 or by going online at
www.winnipeg.ca/police.
CHILD ABUSE REGISTRY CHECK
A Child Abuse Registry Check can be obtained by completing the
Child Abuse Registry Check Request application form and sending it
to the Child Abuse Registry Office. The application forms are
available by contacting the Child Protection Office – contact
information below or on-line at:
www.gov.mb.ca/fs/childfam/child_abuse_registry_form.html.
Whenreturning the completed form to the Child Abuse Registry
Office, a verified photocopy of two pieces of valid identification
and an associated fee payment is normally required. Please refer to
Part 3 of Child Abuse Registry Check form for payment details. The
Child Abuse Registry office will provide the Registry results to
you.
For more information about the Child Abuse Registry Check
process or to mail in your application, contact:
Child Protection 2 - 777 Portage Avenue Winnipeg, MB R3G 0N3
Phone: 204-945-6967 Toll free: 1-800-282-8069 Fax: 204-948-2222
Email: [email protected]:
www.gov.mb.ca/fs/childfam/child_abuse_registry.html.
ADULT ABUSE REGISTRY CHECK
An Adult Abuse Registry Check form can be obtained by contacting
the Office of the Vulnerable Persons’ Commissioner at 204-945-5039
or 1-800-757-9857; Fax number: 204-948-3713; email: [email protected].
The form and instructions on how to complete it will then be mailed
to you.
http://www.gov.mb.ca/fs/childfam/child_abuse_registry_form.htmlmailto:[email protected]:[email protected]
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Once completed, it is to be sent the Adult Abuse Registrar at
the address below. When sending the form to the Adult Abuse
Registrar, a verified photocopy of two pieces of valid
identification is required. The Check is fee-exempt. The Adult
Abuse Registry office will provide the Registry results to you.
Adult Abuse Registry Check Form Mailing Address:
The Adult Abuse Registrar Adult Abuse Registry Unit 2 - 777
Portage Avenue Winnipeg, MB R3G 0N3 204-945-4934
IMPORTANT
When you receive the results of the above Checks, it is your
responsibility as the proposed substitute decision maker to attach
a copy of each of the Checks to the substitute decision maker
application and/or to send them to the Office of the Vulnerable
Persons’ Commissioner.
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Protection of Privacy The personal information that you are
requested to provide is being collected under the authority of The
Vulnerable Persons Living with a Mental Disability Act (the Act).
It is being collected to administer the Act and assist in the
determination of your eligibility to serve as a substitute decision
maker.
This personal information is protected by the protection of
privacy provisions of The Freedom of Information and Protection of
Privacy Act, and under The Personal Health Information Act.
If you have any questions about the collection of personal
information, please contact:
Access and Privacy Coordinator Department of Families 205-114
Garry StreetWinnipeg, MB R3C 4V4Telephone: 204-945-2013
appt_sdm.pdfschedule_a_new.pdfSCHEDULE A
sb_consent_appt_sdm.pdfschedule_c.pdfprotection_privacy.pdfProtection
of Privacy
Last name: Text52: Text53: Birth date mmddyyyy: gender:
Offstreet number street name towncity province postal code: Mailing
address if different from above street number street name towncity
province postal code: living with support personal care home
developmental centre etc: Text2: Text54: Text55: Text56: Text57:
Name of programworkschool: Main contact person at the
programworkschool name title phone number: Attending since: Name of
programworkschool_2: Main contact person at the programworkschool
name title phone number_2: Attending since_2: Name of
programworkschool_3: Main contact person at the programworkschool
name title phone number_3: Attending since_3: Text60: Text61:
Text62: Text63: Text64: Check Box65: OffCheck Box66: OffCheck
Box67: OffCheck Box68: OffCheck Box69: OffCheck Box70: OffCheck
Box71: OffCheck Box72: YesName: Mailing address: Text73: Text74:
Text75: Text76: Mailing address_2: Text77: undefined_3: Text144:
Text145: Mailing address_3: Text146: undefined_5: Text83: Text147:
Text81: 1 Name: Mailing address_4: Text78: Text82: Relationship:
Text85: Text86: 2 Name: Mailing address_5: Text87: Text88:
Relationship_2: Nature and frequency of involvement 1: Nature and
frequency of involvement 2: Text89: Text90: Text91: Text92: Text93:
Text94: Text95: Text96: Text97: Text98: Text99: Text100: Text101:
Text102: 1 Name_2: Mailing address_8: Text103: Text104:
Relationship_5: Nature and frequency of involvement 1_4: Nature and
frequency of involvement 2_4: 2 Name_2: Mailing address_9: Text105:
Text106: Relationship_6: Nature and frequency of involvement_2:
Text107: 3 Name_2: Mailing address_10: Text108: Text109:
undefined_7: Relationship_7: Nature and frequency of involvement_3:
Text110: Text111: Text112: Text113: Mailing address_11: Text114:
Text115: Text116: Text117: Mailing address_12: 1 Name_3: Text118:
Text119: Text120: Text121: Personal care: Check Box27: OffCheck
Box27b: Off1 Name_3a: Text122a: Text119a: Text120a: Text121a:
Personal carea: Check Boxaa: OffCheck Box27bbb: OffMailing
address_13: Text124: Text125: Text127: Text126: Personal care_3:
Check Box1a: OffCheck Box27 1b: OffMailing address_13a: Text124a:
Text125a: Text127a: Text126a: Personal care_3a: Check Box28a:
OffCheck Box29: OffMailing address_13b: Text124b: Text125b:
Text127b: Text126b: Personal care_3b: Check Box30: OffCheck Box31:
OffMailing address_13c: Text124c: Text125c: Text127c: Text126c:
Personal care_3c: Check Box 1g: OffCheck Box27 1h: OffMailing
address_13d: Text124d: Text125d: Text127d: Text126d: Personal
care_3d: Check Box 1j: OffCheck Box27 1k: OffText133: Text134:
decision maker appointment See under Section C part 7 subsection 71
of guide: SDM: Offpast: Offcommittee: OffText141: Text142: appDate:
completed the application in full: Offenclosed supporting documents
noted on page 3: Offcompleted Schedule A real and personal property
if applying for property: Offcompleted Schedule B consent form
signed by the proposed substitute decision: Offenclosed the
Criminal Record Checks and Child Abuse Registry Checks for all:
Offwarranted: OffWhy: duties: OffWhy_2: Text143: Signature of
CSWSocial Worker: socWorkerDate: person_application: BankInvestment
accounts place of deposit balance of each account: Stocks and bonds
estimate of value place of deposit: RRSPs amount place of deposit:
Real estate legal descriptions of civic addresses: Vehicles make
model year: Life insurance policies cash surrender values names of
insurers: Funeral plans cash value place of deposit: Monies owed to
estimate of amounts names of debtors: Other specify: Liability
PersonalProperty loans: balLoans: Liability Credit cards:
balCredit: Liability Other specify: balOther: income_source1:
income_amount1: income_freq1: income_source2: income_amount2:
income_freq2: expenses_source1: expenses_amount1: Frequency_3:
expenses_source2: expenses_amount2: Frequency_4: Date:
subDecisionMakers1: subDecisionMakers2: name of person for whom
substitute decision maker is requested: chkPersonalCare:
OffchkProperty: OffschedBDate: schedBDate2: RESET: