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1 to 6 of 6 forms for the search : Social Solidarity + Special Benefits
Title and description Release Date

Certificat médical (French only) (SR-0040) (PDF, 266 KB)

Form to be completed by a physician. Required to confirm a pregnancy or health condition that entitles the employment-assistance recipient to a special benefit. Submit the completed form in person or by mail to your local employment center.

October 2018

Application for Payment of Medical Transportation (SR-2589A) (PDF, 129 KB)

General form to be used when requesting reimbursement of medical transportation.

April 2017

Application for Payment of Medical Transportation—Therapeutic Activities (SR-2590A) (PDF, 132 KB)

Form to be used when requesting reimbursement of the cost of public transit in order to participate in therapeutic activities. 

February 2016

Application for the payment of funeral expenses (SR-0006FA) (PDF, 157 KB)

Use this form to apply for assistance for payment of funeral expenses following the death of a relative who was the beneficiary of last-resort financial assistance. The deceased’s remaining financial resources must be insufficient to pay for funeral expenses.

The application must be filed with a local employment centre (CLE) and allows you to obtain authorization to have payment of funeral expenses made directly by the Ministère de l’Emploi et de la Solidarité sociale. To find your local employment centre, use the Local Employment Centre LocatorOpens external link in new window.. The authorization will be good for 30 days as of the date indicated by the CLE.

Use this form to apply for assistance for payment of funeral expenses following the death of a relative who was not the beneficiary of last-resort financial assistance benefits, who lived alone and whose remaining financial resources are insufficient to pay for funeral expenses. 

To apply for assistance for payment of funeral expenses following the death of a relative who was not the beneficiary of last-resort financial assistance benefits, who lived as a couple or as part of a family and whose remaining financial resources are insufficient to pay for funeral expenses, use the Application for Service–General Information (3003A) (PDF, 278 KB) and Application for Last-Resort Financial Assistance (3003-02A) forms.

January 2016

Application for payment of moving expenses (SR-0113A) (PDF, 52 KB)

Form required at the request of the local employment centre. Necessary to apply for the special benefit for a move due to an unhealthy living environment (municipal report required) or health reasons (medical report required).

Submit the completed form in person or by mail to your local employment centre.

Dynamic PDF

By default, Acrobat prints documents in letter format. To print this form on legal size paper (8 1/2 X 14), adjust printing configuration.

October 2015

Estimation du coût des médicaments (French only) (SR-2171) (PDF, 106 KB)

Form required by the local employment centre for persons who may be entitled to the claim slips exclusively. This form is intended to provide an assessment, by a pharmacist, of medication costs. 

Submit the completed form in person or by mail to your local employment centre. To find your local employment centre, use the Local Employment Centre LocatorOpens external link in new window..

January 2008