Supplemental Unemployment Benefit Application

Supplemental Unemployment Benefit Application

(All applicable Forms must be completed 100% before submission)
Initial Screening Information
Date of Submission
Month - Day - Year
Last Name
First Name
Middle Name(s)
Date of Birth
dd-mm-yyyy
Are you Bermudian?
Are you a Spouse of a person who possess Bermudian Status?
Copy of Spousal Letter
Filename
Size
Process
Status
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Street Address
Apartment Number/Room Number
Parish
Postal Code
Home Phone Number
Cell Phone Number
Work Phone
Email Address
Were you unemployed as a direct result of COVID-19?

Company Name
Employer Contact Number
Self Employed Tax Number
Were you living in Bermuda on the date (September 17th, 2020) when these Regulations came into effect?
Does your assets in the Bank (including Investments) exceed $5,000?
Do you have any feasible source of income or assets (whether in Bermuda or elsewhere) that are sufficient to provide you coverage with your allowable expenses?
Please indicate the number of Real Properties you have interest in
Are you presently on Financial Assistance?
Are you currently enrolled in a Health Insurance Plan?
Company Name
Policy Number
Social Insurance Number
Copy of Social Insurance Card
Filename
Size
Process
Status
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pdf,doc,docx,jpg,jpeg,png
Please attach a copy of each of the required supporting documents:
Bank Statements (the last three months (3) of your individual and joint bank account statements from date of application)
Filename
Size
Process
Status
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One form of identification (Passport or Voter ID Card ONLY - Driver’s license will not be accepted)
Filename
Size
Process
Status
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Copy of Letter from Employer stating Employment status
Filename
Size
Process
Status
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pdf,doc,docx,jpg,jpeg,png
Other
Filename
Size
Process
Status
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Terms of Agreement
APPLICANT DECLARATION

I agree that the information provided can be relied upon by the Department of Financial Assistance to be true and correct to determine my eligibility for receipt of Supplemental Unemployment Benefit.

I fully understand the information requirements, conditions and terms of assistance stated at the time of interview and agree to provide any supporting material that the Department of Financial Assistance under the Supplementary Benefit program may require.

I further understand that the department will request repayment of assistance received if:
1. I, for the purpose of obtaining any benefit, knowingly misrepresent my circumstances to the Department
2. I knowingly produce or furnish any false documents or information in order to receive Supplementary Unemployment Benefits
I lastly understand that if false, misleading or inaccurate information is submitted, I will be under penalty of suspension or cancelation as stated in the Public Treasury (Administration and Payments) (Supplementary Unemployment Benefit) Regulations 2020 12(1)(a)(b)(c) and 14(1)(2)
CONSENT TO DISCLOSE AND VERIFY INFORMATION
I consent to release the information to an authorized representative of the Department of Financial Assistance for the purpose of determining and verifying my initial and ongoing eligibility for financial assistance by collecting information about myself.

I consent to release information relating to any assets, bank accounts, owned by me or jointly with other individuals, spouse, significant others, dependents or others.

I understand that this consent applies to inquiries made during a period of time which I have been in receipt of Supplementary Unemployment Benefits. I further understand that requests and responses may take the form of electronic data exchange.
Consent

I consent
Last Name
First Name
Middle Name(s)
Important Notice

In accordance with the Public Treasury (Administration and Payments) (Supplemental Unemployment Benefit) Regulations 2020, any person who knowingly makes any false statement or knowingly provides any false information will have committed an offence. Any person who commits an offence is liable on summary conviction to a fine of $1,500 or imprisonment for six months or to both such fine or term of imprisonment.

Household Monthly Expenses
Please do not put commas or dollar signs in the following fields.
Total Monthly Income
Expenses:
Rent
Electricity
Groceries
Telephone
Cooking Gas
Water
Nursery/College Fee
Child Support
Doctors/Bills
Prescription
Cellular
Cable
Loan Payment
Total Expenses
Total Expenses: ${showExpenses}