Last Updated June 2017

The objective of the Self-Employment Assistance Program is to help selected unemployed individuals create jobs for themselves by starting their own business.

Before your application can be asses, it will be necessary for you to receive a needs determination and develop an Employment Plan with a Case Manager. If you do not currently have a Case Manager to assist with the development of your Employment Plan, contact your local Advanced Education, Skills and Labour (AESL) office who can advise you on where to receive this service.

If you are working, do not quit your job, as this may affect your eligibility for assistance.

After you have developed your business idea, your application for Self-Employment Assistance must be approved by the Province, and a Self-Employment Assistance Agreement signed with the Province before you continue to work on your business plan. You will not be approved for Self-Employment Assistance if you have started your business prior to making this application.

Specific documentation must accompany this application. Please see Section F of this form for a complete list.

INFORMATION SHEET

APPLICATION FOR SELF - EMPLOYMENT ASSISTANCE

Environmental issues must be considered and project approval will be subject to all federal and provincial environmental legislation. The proponent is fully responsibly for ensuring that all Policies, Acts and Regulations are followed. Where applicable, proof of such approvals or project consideration will be required. For further information please see http://www.mae.gov.nl.ca/env_assessment/

Personal InvestmentUnder the Self-Employment Assistance Program, the eligible participant must provide evidence of a personal investment. This personal investment is over and above the financial assistance and additional costs.You will be required to demonstrate that you will contribute 25% in personal investment towards the business.

Example: The Province agrees to provide financial assistance for a total amount of $13,000 for the duration of the agreement.

The participant must contribute a personal investment of $3,250 (equal to 25%) in cash or in kind contribution.The following examples could be considered as proof of equity:1. A bank statement showing at least the minimum investment for the proposed venture; 2. Evidence of a loan or line of credit; 3. Proof of ownership of equipment or materials that will assist you in your business.

EligibilityApplicants must be legally entitled to work in Canada.

You must use this application form to make your request for financial assistance under the Self-Employment Assistance Program.

To be eligible for Self-Employment Assistance, a person must meet the definition of an EI-eligible client under the Canada-Newfoundland Labour Market Development Agreement.

General Information

Page 1 of 7DISPONIBLE EN FRANÇAIS

Before this application can be considered for approval you must complete an Employment Plan and a Resumé containing your education and work experience.

Under the Income Tax Act, financial assistance paid to EI Clients is included as income for tax purposes. The Province will deduct tax at source from financial assistance payable to EI Clients with the exception of tuition and dependant care costs.

Income Tax

Applicants are responsible for ensuring, where applicable, that they adhere to the requirements for registration with Service NL pursuant to the Lobbyist Registration Act.Detail with respect to the requirements for Lobbyist registration can be found online at: http://www.servicenl.gov.nl.ca/registries/lobbyists.html 

Note to Applicants Regarding Lobbying

Are you a member of an Aboriginal Group?

APPLICATION FOR ASELF - EMPLOYMENT ASSISTANCE

DATE OF BIRTH (YYYY - MM - DD)

SURNAME GIVEN NAME

ADDRESS

CITY POSTAL CODEPROVINCE

AREA CODE & TELEPHONE NO. E-MAIL ADDRESSOTHER CONTACT TELEPHONE NO.

GENDER

MALEFEMALE

SOCIAL INSURANCE NUMBERSection A - Personal Information

Have you self-identified as having a permanent disability or mental impairment that restricts your ability to perform daily activities? Yes No

If yes, how does this permanent disability or mental impairment restrict your ability to perform daily tasks? Please explain:

Do you consider yourself to be a member of a visible minority? Yes No

Are you a Canadian Citizen? Yes No Permanent Resident? Yes No

What is your preferred Language of Service? English French

What is your preferred Language of Correspondence? English French

Section B - Eligibility

Have you applied for or are you currently in receipt of Employment Insurance? NoYes

Have you had an Employment Insurance claim that ended in the past 60 months? NoYes

Has your business name already been registered? Yes No

If yes, when?

Are you currently active in this business or any other business venture? NoYes

If yes, Please explain:

Section C - Client Goal and ContributionWhat are you contributing towards establishing your own business and how will this contribution be used? This can include in-kind contribution or cash contribution. (25% personal investment)

Last Updated June 2017

NoYes

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Official Use Only Client Agreement Number:

Are you currently employed? Yes No If Yes, please provide hours/week and hourly wage.

Section D - Budget Worksheet and Financial Information

It is necessary that all applicants complete the following budget summary of their monthly income and expenses including the anticipated costs of self-employment to support their application for financial assistance and referral for Self-Employment Assistance.

A - Monthly Income:

Self OtherEmployment IncomeEI BenefitsIncome Support/Social AssistanceAlimony/Child SupportSelf EmploymentPension Income

Workeplace NL Compensation Benefit Canada Pension Plan (CPP)Child Tax Benefits

Disability Income

Severance PayIncome from rental propertiesOtherTotal:

B - Other Anticipated Sources of Funding:

Investment IncomeFamily/Parent/GuardianOther

SavingsAmount

Total:

Property TaxesUtilitiesTelephoneClothing

Rent/Mortgage/ Room and Board

Food

Child Care (after subsidy)Insurance (car, life and house)EntertainmentCredit Card/Loan Payments

Transportation

Alimony / Child SupportExpenses for disability needsStudent LoansMiscellaneous ExpensesTotal:

$

Amount

C - Monthly Expenses:

D - Incremental Costs Associated with Self-Employment:Amount

Weekly Basic Living Costs

Disability NeedsTransportationOther Personal SupportsLiving Away From Home

Dependent Care

Other Costs Total:

Tuition for Entrepreneurial Training

Last Updated June 2017

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $

$ $ $ $ $ $ $ $ $ $ $ $ $ $ $

$ $ $ $ $ $ $ $ $

$ $

$

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Instructions:

Section E - Declaration - Amounts owing in Default to the Province

The information you provide below is collected in accordance with the Canada-Newfoundland and Labrador Labour Market Development Agreement.   While the completion of this declaration is optional, failure to do so may result in denial of funding.

If yes, please complete the following chart:

Do you, the applicant, owe any amounts that are in default to the Province? Any such amounts are limited to those: a) resulting from Newfoundland and Labrador Benefits and Measures contribution agreements; and b) having been established after November 2, 2009.

Amount in Default Owing

Newfoundland and Labrador Benefits and Measures Client

Agreement Number

Nature of the Amount in Default Owing (penalties, overpayments)

$

$

$

$

4

4

Yes No

The following documents must be completed to support your request for Self-Employment Assistance . Please check that each item has been completed and is on file with your Case Manager.

Section F - Supporting Documentation

Employment Plan that identifies the appropriateness of Self-Employment and employment barriers Letter of support and rationale from the Self-Employment Coordinator Resumé which includes the applicant's education and work history Summary of Business Concept Evidence of a Personal Investment Documentation relating to environmental issues, if applicable Other supporting documents - such as proof of personal investment Documentation to support request for additional costs

Last Updated June 2017 Page 4 of 7

If yes, do you currently have arrears owing under any support order(s)?

Note: The processing of your application will include independent verification of your status with respect to Support Orders. This may result in garnishment of a portion of any approved NLBM funding, under subsection 15.(2) (a) and section 19 of the Support Orders Enforcement Act, 2006 SNL 2006, c.S-31.1, for payment of any arrears owing.

Do you currently have any orders or judgment for support, maintenance or alimony against you?

If yes, please provide the particulars of the arrears:

E - Support Orders:

NoYes

NoYes

Name of Applicant:

Date: (YY/MM/DD)Signature of Applicant:

NLBM 5260E (2014-03) Page 5 of 7

Application received by the Province: Date: (YY/MM/DD)

I declare that:

(a) I have read and understood the information provided in this application package;

(b) the information I have provided to the Province in this application and supporting documentation is true, accurate and complete in every respect;

(c) if the information described above is false or misleading, I may be required to repay some or all of the financial assistance that may be approved by the Province; and

(d) the information provided, with respect to amounts owing in default to the Province, is true and accurate. Any such amounts are limited to those: i) resulting from Newfoundland and Labrador Benefits and Measures contribution agreements; and ii) having been established after November 2, 2009. I recognize that any such amounts owing to the Province may be deducted from, set-off against, or recovered by other means from amounts payable to me under any contribution agreement.

Attestation:

Statement from SEA Case Manager:

I, (name of SEA Coordinator), SEA Agreement # have completed an assessment of this client's employment situation and agree or disagree that the Newfoundland and Labrador Self-Employment Assistance Benefit applied for is most appropriate to assist the client in obtaining employment for the following reasons:

Telephone Number:

Date: (YY/MM/DD)

Signature:

(name), working for

Page 6 of 7Last Updated June 2017

Collection: Personal information provided with your intake form / application for funding is collected under authority of the Access to Information and Protection of Privacy Act, 2015 (ATIPPA, 2015), Employment Insurance Act of Canada, Income and Employment Support Act and Regulations, and will only be used for the administration of the service or benefit for which you are applying or for a consistent purpose under section 69 of ATIPPA, 2015. Use: The personal information collected will only be used and/or disclosed in accordance with ATIPPA, 2015. Such uses may include: determining services appropriate to the needs of the client, determining eligibility for programs and funding, ensuring compliance with funding agreement terms, case management, tracking progress during an agreement including post funding assessment of outcomes as per the information sharing agreement referenced between the Government of Canada and the Government of Newfoundland and Labrador funded by the Department of Advanced Education and Skills and to provide statistical information to agencies providing funding support to the services offered. Disclosure: The personal information provided may be exchanged and released to any person, agency or government departments such as Advanced Education and Skills, and Health and Community Services, service provider organizations or training institution that is administering the program, service or benefit. This information may include: contact information, employment plan, eligibility for employment insurance benefits, marks, attendance and proof of financial payments to the training institution. The personal information provided may also be shared with the Government of Canada and the Canada Revenue Agency in keeping with the data-sharing provisions outlined in agreements between the Government of Newfoundland and Labrador and the Government of Canada. Access to Information and Protection of Privacy Act, 2015: Under ATIPPA, 2015 personal information is protected in accordance with section 64.(1); you have the right to access your personal information protected in accordance with section 8.(1); and you have the right to request the correction of your personal information protected in accordance with section 10.(1) if there has been an error or omission. You have the right to withdraw this consent at any time by contacting the Department of Advanced Education and Skills. If you have any questions regarding how your personal information is collected or used, you may contact the ATIPP Coordinator of the Department of Advanced Education and Skills. A listing of all departmental coordinators and their contact information can be found at: www.atipp.gov.nl.ca/info/coordinators.html.

Access to Information and Privacy