Canadian Emergency Response Benefit Form

Date:* Unit:*

Dear Member(s):
This form confirms that you / persons in your household are or have been in receipt of The Canada Emergency Response Benefit (CERB). Please fill it out completely and return it to the co-op office as soon as possible. I/ we are in receipt of the CERB for the following periods:

Start Date:* End Date:*

Name: Date:

Signature(type full name):

Name: Date:

Signature(type full name):

Name: Date:

Signature(type full name):

(please enter names of all household members in receipt of CERB)

The co-op office will assume that you will also receive subsequent lump-sum payments; please advise us immediately if this is not the case.

Thank you.

Ali Parrott