This form is used by personal care home residents and their families/representatives to request a waiver of their assessed residential/authorized charge. This form is applicable to Manitoba Health, Seniors and Active Living, personal care home facilities and those residents requesting a waiver of their assessed residential/authorized charge and their families/representatives. The form is filled out by the personal care home resident or their representative, by the personal care home facility and by Manitoba Health, Seniors and Active Living. The form is processed by Manitoba Health, Seniors and Active Living.