Declaration of Income
Identification
Last and first names
File number (CP-12)
Social insurance number
Telephone
Current situation
Please answer the following questions, to enable Emploi-Québec to check whether you are entitled to receive one of the
following amounts while participating in an eligible activity:
• a $ 45-per-week employment-assistance allowance;
or
•$ 9 per day to cover incidental expenses.
Place of residence
Number of people in your family (See definition of “family” below.)
Report your income and your family’s income earned in the last twelve months. (See definition of “income” below.)
$
Your income in the last twelve months:
Income of other family members:
+$
Total income in the last twelve months:
=$
Declaration
I solemnly declare that the information I have given on this form is accurate and complete.
Date
Signature
In accordance with the Act respecting Access to documents held by public bodies and the Protection of personal information, all the personal i­nformation given on this form
is confidential.
Low Income Cut-offs (before tax) – 2014
based on Statistics Canada’s low income cut-offs
Size of Family Unit
Population of Area of Residence
Rural Areas
outside CA
Note 1
or CMA
Less than
30,000 Note 2
30,000 99,999
100,000 499,999
500,000
or more
1 person
$16,747
$19,053
$20,822
$20,952
$24,328
2 persons
$20,849
$23,718
$25,921
$26,082
$30,286
3 persons
$25,630
$29,158
$31,866
$32,065
$37,234
4 persons
$31,120
$35,403
$38,691
$38,931
$45,206
5 persons
$35,294
$40,153
$43,883
$44,154
$51,272
6 persons
$39,808
$45,287
$49,493
$49,800
$57,826
7 persons or more
$44,319
$50,420
$55,103
$55,444
Census agglomerations (CA)
Note 1: Can include some small population centres.
Note 2: Including population centres with less than 10,000 inhabitants.
Definitions
Census metropolitan areas (CMA)
$64,381
Source: Statistics Canada
Family:
A family is composed of
• An independent adult with or without dependent children1;
• An emancipated minor2 with or without dependent children;
• A minor with dependent children;
• Two spouses3 with or without dependent children.
1. A minor child who is neither fully emancipated, nor the father or mother of a dependent child, or a child of full age who
attends an educational institution at the secondary level (minimum 15 hours a week), the college level, or the university level (minimum 12 credits per term).
2. Minor children who have become fully emancipated, by way of a decision handed down by the Superior Court or by
way of marriage.
3. Persons who are married or in a civil union with each other and who cohabit; persons of opposite sex or the same sex
who cohabit and who are the mother and fatner of a child; persons of full age of the opposite or the same sex who live
together in a de facto union and who, at any one time, cohabited for a period of not less than one year.
Note that more than one family may reside in the same residence.
Income:
Gross salary and earnings, net self-employed income, investment income, government transfer payments, employment
insurance and social assistance or social solidarity benefits, CSST and SAAQ compensation payments, retirement pensions and ­annuities, alimony, scholarships and other income.
Low-income threshold: Families living with incomes under these levels usually spend 54.7% or more of their income on food, housing and c­ lothing.
Rural Areas:
Populated areas located outside Census aggomeration (CA) or Census metropolitan areas (CMA).
Ministère du Travail, de l’Emploi et de la Solidarité sociale
EQ-6468A (09-2015)