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S-4.2, r. 13 - Regulation respecting the assessment of the needs of a person requesting emergency lodging as a victim of violence

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SCHEDULE II
(s. 3)
REGISTER OF FORMS “SHORT TEST FOR NEEDS AND RESOURCES”
O.C. 1401-92, Sch. II; O.C. 1797-2022, s. 3.
SCHEDULE II
(s. 3)
REGISTER OF FORMS “SHORT TEST FOR NEEDS AND RESOURCES”
Gouvernement du Québec REGISTER OF FORMS
Ministère de la Santé et des Services sociaux “SHORT TEST
FOR NEEDS AND RESOURCES”

Name of shelter For the period ending 31 March ______________
Administrative region File No.


Form No. Number of children DAYS PRESENT File No. *
(P) Income* * Available liquid
personal income
Adults Children
A
B
A
B
A
B
A
B
A
B
A
B
A
B
A
B
A
B
A
B
A
B
A
B
A
B
A
B
A
B

* Check here if the person is receiving last resort financial assistance under the Individual and Family Assistance Act.
** A) Available monthly personal income B) Federal benefits includes in A Page
Data collected from persons not receiving last resort financial assistance under the Individual and Family Assistance Act
O.C. 1401-92, Sch. II.
© Gouvernement du Québec