This form is used by personal care home facilities to determine and verify a resident's and their spouse's annual income, and by Manitoba Health, Seniors and Active Living to determine the resident's entitlement to a reduced residential/authorized charge. This form is applicable to Manitoba Health, Seniors and Active Living, personal care home facilities and those residents applying for a reduced residential charge and their families/representatives. The form is filled out by the personal care home resident or their representative and by the personal care home facility. The form is processed by the personal care home facility and by Manitoba Health, Seniors and Active Living.