ESDC EMP5610 (2015-01-001) E
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PROTECTED WHEN COMPLETED - B
Développement social Canada
Social Development Canada
(Personal Information bank: PPU 038)
APPLICATION: Canada Disability Savings Grant and/or Canada Disability Savings Bond
1. Complete this annex if the beneficiary is 18 years of age or under at the time of the application or was 18 years or under during any part of the ten-year
period (starting in 2008) prior to the application if the beneficiary was eligible for the Disability Tax Credit for any of those years.
2. A separate annex is to be completed for each primary caregiver.
3. The personal information of the primary caregiver from previous years is used to determine if the beneficiary is entitled to any grant or bond
from those years. All primary caregivers for each of these years will need to complete an Annex B.
4. Read this document carefully. If you have any questions, do not hesitate to ask the Registered Disability Savings Plan (RDSP) issuer.
5. This form is valid only if completed, signed, dated and given to the RDSP issuer. Do NOT send directly to Employment and Social Development
6. Keep a copy for your records.
RDSP Contract No.
B-1 Information About the Primary Caregiver
You are a primary
caregiver if you are/
were the person eligible
for the Canada Child
Tax Benefit (CCTB) and
whose name appears
on the CCTB payments.
For more information
please refer to B-4.
Complete the following information if:
Beneficiary's Last Name Beneficiary's First Name Beneficiary's Middle Name
B-2 Declaration and Consent of the Primary Caregiver
You must read this
section and sign in order
for the beneficiary’s
RDSP to receive grants
I understand that the provision of the information is voluntary and that I am not required to give my consent;
however, if I do not give my consent, the Government of Canada may not be able to pay the grant and/or bond to
the issuer in respect of this RDSP.
I confirm that I have read, understood, and received a copy of this document, including the privacy rights found in
Section B-4, and I consent to the use and sharing of my personal information as outlined.
B-3 Agency Attestation
If applicable, this
attestation must be
completed in order
for the beneficiary’s
RDSP to receive
grants and bonds.
Ce formulaire est disponible en français
This form is available in alternate formats
Last Name First Name Middle Name
Social Insurance Number / Business Number (if an Agency)
ANNEX B – Primary Caregiver
Primary Caregiver’s Signature
• you are/were a primary caregiver of the beneficiary; or
• you are/were an agency in the case where the beneficiary is/was a “child-in-care” and a payment under the
Children’s Special Allowances Act was made in at least one month in the calendar year for any year that the
beneficiary was 18 years or younger within the last ten years (starting in 2008).
The name must be entered exactly as it appears on Social Insurance Number or Business Number documentation.
Name of Agency Name of Agency Representative
Complete this section if you are an individual.
I confirm that the agency identified above was issued a payment under the Child Special Allowances Act in the
current calendar year, or if applicable, I confirm that the agency identified above was issued a payment under the
Child Special Allowances Act in the following previous calendar year(s):
Signature of Agency Representative
Complete this section if you are the agency that received a payment was made under the Child Special Allowances
Act in respect of the beneficiary in at least one month in the calendar year(s).
The Government of Canada needs to collect information on the primary caregiver for the years in which the beneficiary is 18
years of age or under in order to determine the amount of grant or bond. Your personal information is also used to verify
Information on the primary caregiver is used to determine the family income for a particular year, as well as to validate the
beneficiary’s residency and eligibility for the DTC. Family income is based on the second preceding tax year (for example,
family income for determining 2014 bond entitlement is based on the 2012 tax year). Your personal information held by the
Canada Revenue Agency is used to determine the family income as well as validate the beneficiary’s Disability Tax Credit
eligibility and the beneficiary’s residency.
As the beneficiary may be eligible for unused grant and bond entitlements from the previous ten years (starting in 2008) the
personal information of the primary caregiver is used to determine eligibility for any year in which the beneficiary was under
19 years of age. As noted above, the family income is based on the second preceding tax year and, as a result, the use and
sharing of personal information may extend as far back as 2006.
B-4 Your Privacy Rights
This section explains
why your information is
collected and how it is
used, shared and
protected. It also
explains how you can
access your personal
The use of the singular
(such as primary
caregiver) also includes
plural as the context