Disability Tax Credit (DTC): Qualification Form

The Disability Tax Credit (DTC) allows someone living with a mental or physical impairment to receive substantial financial benefits and credits. Such benefits may include, but are not limited to:

• a significant refund from the Federal Government (often thousands of dollars);
• monthly benefits;
• access to the Disability Bond (up to $20,000);
• access to the Disability Grant (up to $70,000);
• and much more.

Please use this brief survey to determine if you should make the effort to qualify for the DTC.

If you are using this survey on behalf of another person (for example, your child), please answer as if you are them.

Has your impairment in physical or mental functions lasted, or is it expected to last, for a continuous period of at least 12 months?

Has your impairment in physical or mental functions lasted, or is it expected to last, for a continuous period of at least 12 months? Yes No I am not certain
Please select ALL that apply:

Please select ALL that apply: You are blind. You receive life-sustaining therapy. Examples include cancer patients, Type I Diabetes, etc. The impairment restricts you in one or more basic activities of daily living (mental and/or physical). For example, you have difficulty walking or getting dressed (physical), or it takes you longer to learn information (mental).

Examples of these types of impairments include: Autism, MS, PTSD, Severe Pain, etc.
Do the effects of your impairment cause you to be markedly restricted all or substantially all of the time (at least 90% of the time) in one or more of the basic activities of daily living, even with the appropriate therapy, medication, and devices?

Do the effects of your impairment cause you to be markedly restricted all or substantially all of the time (at least 90% of the time) in one or more of the basic activities of daily living, even with the appropriate therapy, medication, and devices? Yes No
Please state the nature of the impairment(s) - if there is more than one, list all of them:
Please indicate the age range of the individual living with the impairment:

Please indicate the age range of the individual living with the impairment: less than 18 years of age between the ages of 19 and 49 years old over age 49
Has your doctor prescribed medication to help with the impairment?

Has your doctor prescribed medication to help with the impairment? Yes No
What is the name of the medication and the dosages?
Please tell us how your impairment impacts your day-to-day living. For example, does it take you significantly longer to complete routine tasks, do you have difficulty learning new things, or does the impairment impact your performance at work and/or school?
On a scale of 1-to-10, please indicate the severity of the impairment (in your opinion).

1-3 Mild
4-7 Moderate-to-more-severe
8-10 Severe

We are not asking for a medical opinion, just how severe you believe the impairment to be impacting your life:
Are you currently receiving any disability benefits from the province?

Are you currently receiving any disability benefits from the province? Yes No
Please tell us anything that you feel is important:
Contact and Provincial Information
Your Name: Your Name: First Last
Your Email Address:

Confirm Email Address:
Phone:
(you will be contacted ONLY if it is deemed that you should move forward with the application process) Phone:
(you will be contacted ONLY if it is deemed that you should move forward with the application process) - ### - ### ####
Your Province of Residence:
Our Awareness Campaign

Please take a moment to tell us how you first became aware of the Disability Tax Credit (DTC).
How did you first learn about the Disability Tax Credit?

How did you first learn about the Disability Tax Credit? My Disability Benefits Specialist Someone referred me to RDSP Canada My doctor My charity Social media Other (please state) Other (please state)
Please provide the name of the person who referred you: Please provide the name of the person who referred you: First Last
Please provide the name of your Benefits Specialist: Please provide the name of your Benefits Specialist: First Last
For Benefits Specialist's use ONLY
Are you a Benefits Specialist?

Are you a Benefits Specialist? Yes No
As a Benefits Specialist, please enter your email address to receive a copy of this form to assist your client:
Release of Information

By submitting this form, you acknowledge that you are allowing us to share the information contained herein to help you apply for the Disability Tax Credit (if required). You may, at any point in time, discontinue this process. We agree to value your privacy and not share any of your information other than for the aforementioned purposes.
Please check:

Please check: I have read the 'Release of Information' and agree to the sharing of this form when required for the Disability Tax Credit (DTC) Certificate.

Disability Tax Credit (DTC): Qualification Form

Disability Tax Credit (DTC): Qualification Form

Contact and Provincial Information

Our Awareness Campaign

For Benefits Specialist's use ONLY

Release of Information