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Application to the Appeal Division - Income Security Également disponible en françaisYou may apply for permission (leave) to appeal a decision of the General Division to the Appeal Division. Begin the process by sending this completed application form to the Tribunal. The Tribunal must receive your application form within 90 days after the day on which you receive the General Division decision. You may also use the form to appeal to the Appeal Division if the General Division summarily dismissed your appeal. You should submit your appeal as soon as possible. Refer to the Instructions for an "Application to the Appeal Division - Income Security" form for additional information. Please PRINT in ink or TYPE 1 - Application (see instructions for details)I am:

Appealing a General Division summary dismissal decision

Appealing any other General Division decision

2 - Appellant / Contact Person InformationTribunal File Number at General Division (it begins with GP or GT)

The appellant is: An individual

The Minister of Employment and Social Development Canada

Individual

First Name of Appellant

Last Name of Appellant

Minister of Employment and Social Development Canada

First Name of Contact Person for this Application

Last Name of Contact Person for this Application

Title

3 - Address and Contact InformationHome / Business Address (No., Street, R.R.) Apt. / Unit City / Town

Province / Territory Postal Code Country

Do you have a telephone number?No Yes (If yes, you must provide it)

Telephone Number including Area Code Other Telephone Number including Area Code

Do you have a fax number?No Yes (If yes, you must provide it)

Fax Number including Area Code

Do you have an email address?No Yes (If yes, you must provide it)

Email Address

Mailing address :

Province / Territory Postal Code Country

City / TownApt. / UnitAddress (No., Street, R.R.)

Same as above (go directly to Section 4)

Different from Home / Business address (complete this section, then go to Section 4)

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4 - CommunicationsPlease write to me in:

English FrenchIf there is a hearing, I want the language at the hearing to be:

English French

I cannot communicate effectively in English or French and if there is a hearing, I will need an interpreter.

5 - Appeal of the General Division DecisionYou must attach a copy of the General Division decision to this form.

I am attaching a copy of the General Division decision.

I received this decision on:Year - Month - Day

or I do not remember when I received the General Division decision.

6 - Application for Leave to Appeal (permission) DeadlineImportant: You have 90 days from the time you received the General Division decision (other than a summary dismissal decision) for your application to be received at the Tribunal. If your application is late, you must explain why. Please see the Instructions for an Application to the Appeal Division for additional information on how to explain why your application is late. A Tribunal member will decide if your late appeal can go forward. If your application is late, use the following space to explain why.My appeal is late because (use extra paper if you need it):

7 - Reasons for Application (see instructions for what to include)A) I am filing this “Application to the Appeal Division” for any of the following three reasons (To be completed when applying for leave to appeal and when appealing a summary dismissal decision): (choose all that apply)

The General Division failed to observe a principle of natural justice or otherwise acted beyond or refused to exercise its jurisdiction

The General Division made an error in law in its decision

The General Division made an important error regarding the facts contained in the appeal file

Please explain in detail why you selected any of the three reasons (use extra paper if you need it):

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B) I understand that I first need permission (leave to appeal) from the Appeal Division to file an appeal. I believe my application for leave to appeal has a reasonable chance of success for the following reasons (to be completed when appealing a General Division decision, other than a summary dismissal decision. (use extra paper if you need it):

8 - Representative Information

I am represented by:I am representing myself. Go directly to Section 10.

The same Representative I had at the General Division. Go directly to Section 10.

I have a new Representative. Complete this section with your Representative's information and have your Representative sign and date Section 9, then go to section 10.

First Name Last Name

Name of company, association, or organization if applicable (optional)

Address (No., Street, R.R.) Apt. / Unit City / Town

Province / Territory Postal Code Country

Telephone Number including Area Code Other Telephone Number including Area Code (optional)

Does your Representative have a fax number?No Yes (If yes, you must provide it)

Fax Number including Area Code:

Does your Representative have an email address?No Yes (If yes, you must provide it)

Email Address:

9 - Signature of RepresentativeSignature of Representative Year - Month - Day

10 - Declaration and Signature of AppellantI declare that all the information and supporting documentation in this Application to the Appeal Division form are true to the best of my knowledge. In addition, when the Appellant has appointed a representative: I authorize the Tribunal to disclose any information about my appeal to my Representative, either orally or in writing. I understand that the Tribunal will communicate only with my Representative and that I will personally receive information only about the hearing and the final decision.

Signature of Appellant Year - Month - Day

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Privacy Notice StatementThe information you provide is collected under the authority of the Department of Employment and Social Development Act (DESD Act) and the Old Age Security Act and the Canada Pension Plan for the purpose of filing an Application to the Appeal Division. Providing your personal information is voluntary, but refusal to provide the specified personal information may prevent the appeal from being properly filed. The information you provide will be shared with all the parties to the appeal, including Employment and Social Development Canada (ESDC), and may also be shared with ESDC for the purpose of reporting. The information you provide may be used and/or disclosed for policy analysis, research and/or evaluation purposes. However, these additional uses and/or disclosures of your personal information will never result in an administrative decision being made about you. Your personal information is administered in accordance with the DESD Act, the Old Age Security Act, the Canada Pension Plan, the Privacy Act and other applicable laws. You have the right to the protection of, and access to, and correction of your personal information. It will be retained in Personal Information Bank PPU 116 and PPU 146. Instructions for obtaining this information are outlined in the government publication entitled Info Source, which is available at the following website address: www.canada.ca/infosource-ESDC Info Source may also be accessed online at any Service Canada Centre. You have the right to file a complaint with the Privacy Commissioner of Canada regarding the institution's handling of your personal information at: www.priv.gc.ca/

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Instructions for an Application to the Appeal Division - Income SecuritySubmitting Your Application You may submit your completed Application to the Appeal Division form and the General Division decision by mail, fax or email: Mail Social Security Tribunal of Canada Attention: Appeal Division (AD) PO Box 9812 Station T Ottawa, ON K1G 6S3 Fax 1-855-814-4117 (toll free) Email* info.sst-tss@canada.gc.ca Please submit only one copy of your “Application to the Appeal Division” form and General Division decision, and then wait for the Tribunal to send you an acknowledgement letter. If you send two or more copies of your documents, this may cause a delay in processing your appeal. *Documents that contain a signature should be scanned if sent by email. Please note that email is not a secure form of communication. Any information contained in emails or in documents attached to emails, including personal information, could be intercepted, accessed or stored by third parties.

Questions? Call the Tribunal between 7 a.m. and 7 p.m. Eastern Time (ET) 1-877-227-8577 (toll free from inside Canada or the United States) 1-613-437-1640 (collect call from outside Canada or the United States) TTY 1-866-873-8381 Website www.canada.ca/en/sst/

Deadline for Filing an AppealYou can use this form to appeal a General Division summary dismissal decision as well as to request permission to appeal any other General Division decision. If you received more than one General Division decision, you will need to complete one form for each one of the decisions you want to appeal. Deadline: within 90 days after the date you received the General Division decision, for all decision other than a summary dismissal decision. The Tribunal can register your appeal or application for leave to appeal only when it has received a complete "Application to the Appeal Division" form and a copy of the General Division decision. Your complete "Application to the Appeal Division" form and General Division decision must be received by the deadline otherwise you will need to request an extension of time. The tribunal will contact you if requires information is missing from the "Application to the Appeal Division" form. If your appeal is late, it is up to a Tribunal member to decide if the appeal can still go forward. Deadline for filing an appeal of a summary dismissal decision: Although there is currently no deadline to appeal a summary dismissal decision, you should submit your appeal as soon as possible. Filing your appeal by mail? The Tribunal must receive your "Application to the Appeal Division" form by the deadline date. Filing your appeal by fax? The Tribunal must receive your "Application to the Appeal Division" form before midnight of the deadline date, Eastern Time.

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Changes to Contact InformationPlease always keep your contact information up to date. You must let the Tribunal know as soon as possible when your contact information changes. Call, email, or send a letter by mail to the Tribunal when, for example, you move or change your telephone number. If you do not keep your contact information up-to-date, it could result in the Tribunal being unable to reach you or send you important information. Your appeal could also proceed in your absence. Representatives should also keep their contact information up to date.

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Record-KeepingPlease keep the originals of any documents you send to the Tribunal (for example: your completed "Application to the Appeal Division" form and any other documents). Please also keep any letters or documents the Tribunal sends to you, in the order that you have received them, as they are numbered. Parties may find it helpful to add these documents to a binder in the order they are received to ensure they have easy access to their complete file throughout the process.

Information About the “Application Requesting Leave to Appeal” FormSection 1Decision of the General Division include:

• summary dismissals, and • other decisions made by the General Division

An appeal to the Appeal Division is different from an appeal to the General Division. At the Appeal Division, a Tribunal member reviews the General Division decision to determine if there was an error made or if procedural fairness was not respected. It is not normally an opportunity for the parties to introduce new facts. Please read the instructions under sections 5 and 6 for what information is needed for your appeal. It is important to clarify whether the decision you are appealing was a summary dismissal decision or another decision of the General Division. The steps of the appeal process are different depending on the type of decision. For example to appeal a summary dismissal decision you do not need permission from the Appeal Division to file an appeal, but you do need permission for any other decisions made by the General Division. The “Application to the Appeal Division” form can be used for all of these types of appeals.

IMPORTANT • If you are appealing a General Division summary dismissal decision, you do not need to fill out sections 6 and 7B. To confirm whether or not

the General Division summarily dismissed your appeal, check the cover letter accompanying the General Division decision. If your appeal was summarily dismissed, the subject line of the letter will be “Decision - Summary Dismissal”.

• If the cover letter accompanying the General Division decision does not mention “summary dismissal” in the subject line, then you need to ask the permission (“leave to appeal”) of the Appeal Division in addition to including reasons for the appeal (complete both sections 7A and 7B).

• If you are not sure of the type of decision issued by the General Division please call the Tribunal for additional clarification.

Section 2Make sure you include the Tribunal file number at the General Division, it starts with GP or GT. Minister of Employment and Social Development Canada: When appealing a General Division decision, the Minister must provide contact information for the purpose of this application.

Section 3Make sure your contact information is correct. The Tribunal will contact you using this information. You may miss important information about your appeal when your contact information is incomplete or inaccurate. Your appeal file may also be closed if the Tribunal is unable to contact you.

Section 4Choose the official language in which you want the Tribunal to write to you: English or French. Also choose the official language you want used at the hearing (if there is a hearing).

You must include a copy of the General Division decision with your appeal. You must provide the date you received the General Division decision. If you do not remember the date check the box “I do not remember”. In this case, the Tribunal will normally consider the decision received ten (10) days after the date it was mailed by the General Division.

Section 5

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The Tribunal must receive your complete “Application to the Appeal Division” form and a copy of the General Division decision by the deadline. The deadline is 90 days after the day on which you received the General Division decision, for all decisions other than a summary dismissal decision. Complete this section only if your application is late. Late application for leave to appeal (do not complete this section if you are appealing a summary dismissal decision): When your application for leave to appeal is late, you must explain why. A Tribunal member will decide if they will grant an extension of time so that your appeal will still move forward. You may use additional paper if you do not have enough space on the form. Provide the information to explain to the Tribunal member the reasons for the delay in filing your appeal:

• Explain why your appeal is late; • The steps you took that show that you were always planning to appeal (continued intention); • The arguments you have to support your appeal and show that it has a chance of success; and • Why allowing the late appeal is not unfair to the other party.

The Tribunal cannot accept an application for leave to appeal filed more than one year after the day on which you received the General Division decision.

Section 6

Section 7REMINDER

• If it is an appeal of a summary dismissal decision, complete only Part A.

• For any other appeal of a General Division decision, complete both Part A and Part B.

Part A Under the law, an appeal before the Appeal Division is different than an appeal before the General Division. An appeal before the Appeal Division is not a second opportunity for parties to present their case and show they are entitled to a benefit under the Canada Pension Plan and the Old Age Security Act. You can appeal to the Appeal Division for any of only the following three reasons: Reason #1: The General Division failed to observe a principle of natural justice or otherwise acted beyond or refused to exercise its jurisdiction. For example, an appellant submitted a medical report to the General Division, but the document was not included in the appeal file. Reason #2: The General Division made an error in law in its decision. For example: the General Division member based the decision on the wrong section of the applicable law. Reason #3: The General Division made an important error regarding the facts contained in the appeal file. For example, the General Division member indicated in the decision that there was no medical report submitted by the appellant when one had been submitted and was in the appeal file. You must identify which of the reason(s) apply to your case and provide as much detail as possible. It is not sufficient to indicate that there was an error or that natural justice was not respected. You must explain what the error was or how natural justice was not respected. You can refer to specific pages of documents on file or to paragraphs in the General Division decision. You may use additional paper if you do not have enough space on the form. Part B If you are appealing any decisions other than a summary dismissal decision, you must request permission to file an appeal. This is called “leave” to appeal. You have to explain why your application to the Appeal Division has a reasonable chance of success. You may use additional paper if you do not have enough space on the Form.

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Section 8You must indicate if you will present your own appeal, or if someone else will represent you. If you will be represented you must indicate if you will continue with the same Representative you had before or if you will have a new Representative. The Tribunal will not automatically transfer your Representative's information from your appeal file at the General Division to your appeal file at the Appeal Division. Your Representative may be a family member, friend, agency worker, lawyer, or another professional. If you have a Representative, Section 8 must be completed. It must be signed by your Representative in Section 9, unless you have the same representative you had for your appeal at the General Division. Employers and businesses may be represented by a staff member. If you have completed this section of the application form you do not need to also complete the “Authorization to Disclose” form. When you choose to have a Representative act for you, you are giving the Tribunal permission to share your information and communicate directly with that person about your appeal. The Tribunal will send information to your Representative and it will be up to your Representative to keep you informed. You are responsible for any costs associated with your Representative. Change to Representation: You must let the Tribunal know as soon as possible if you change your Representative, decide not to have a Representative any more, or decide to get a Representative. Call, email, or send a letter to the Tribunal right away. You may find the “Authorization to Disclose” form, available on the Tribunal's website, helpful. Note that there are different provincial rules about who may practice law, and Tribunal members may have to follow these rules. You may wish to discuss this with your Representative and/or consult your provincial/territorial law society.

Section 10

By signing the “Application to the Appeal Division” form, you are saying that the information provided in the form and the documents you send in with the form are true to the best of your knowledge.

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