Certificate/Duty Counsel Guaranteed Daily Rate Account Page 2 As duty counsel I assisted the following persons: Please print legibly or type Does client identify as First Nation, Métis, Date of Service Service Service Inuit? Birth Financial Eligibility Name 1 2 3 Insert up to 3 service numbers Not Not Newly No from Legend, include 0 for (Surname, First Name) Yes No Asked (mm/dd/yyyy) Eligible Eligible Eligible Test services 01 09 –
Certificate/Duty Counsel Guaranteed Daily Rate Account Page 2 As duty counsel I assisted the following persons: Please print legibly or type Name Does client identify as First Nation, Métis, Inuit? Date of Birth Financial Eligibility Service 1 Service 2 Service 3 (Surname, First Name) Yes No Not Asked (mm/dd/yyyy) Eligible Not Eligible Newly Eligible No Test Insert up to 3 service numbers from Legend, include 0 for services 01 – 09
FORM_20-GDR_Accounts.docx