0207809
LA
Change in Percentage of Custody Time
Child assistance
You must complete this form only if the percentage of time you have custody of a child changes for one of the following reasons and you are
already receiving child assistance payments for the child:
The child was living with you more than 60% of the time and is now in shared custody.
The child was in shared custody and is now living with you more than 60% of the time. If that is the case, the form must also be signed
by the other person who was entitled to payments for the same child.
We determine that a child is in shared custody when the child lives with each parent between 40% and 60% of the time each month.
Example: 40% = 3 days a week, 50% = every second week, 60% = 4 days a week.
If you have never received child assistance payments for this child, you must apply for them. You can file your application directly on
our Web site at www.retraitequebec.gouv.qc.ca. You will avoid any postal delays and we can confirm immediately that we have received
your application.
Indicate your social insurance number
Please print
1. Information about your identity
Sex
Family name
F
M
Date of birth
year
month
day
Given name
Your mother’s family name at birth (last name only)
Your address (number, street, apartment)
City
Province
area code
Telephone
What is your relation to the child?
Father
Country
Postal code
area code
OtherExtension
Mother Other, please specify:
2. Information about the person who is affected by the change
Sex
Family name
Given name
F
Date of birth
year
M
City
month
day
Address (number, street, apartment)
Province
area code
Telephone
What is your relation to the child?
Father
Country
Postal code
area code
OtherExtension
Mother Other, please specify:
3. Information about the child for whom the custody time has changed
Sex
Family name
Given name
F
M
Date of birth
year
month
day
His or her mother’s family name at birth (last name only)
Indicate the percentage of time, on a monthly basis, that the child lives with:
You
% + the other person
année
Since when?
Retraite Québec
mois
jour
% = 100%
For example : 3 days a week = 40%
Every second week = 50%
4 days a week = 60%, etc.
LPF-809A (16-01)
Another child for whom the custody time has changed (if applicable)
Sex
Family name
Given name
F
Date of birth
M
year
month
day
His or her mother’s family name at birth (last name only)
Indicate the percentage of time, on a monthly basis, that the child lives with:
You
% + the other person
année
mois
% = 100%
jour
Since when?
For example : 3 days a week = 40%
Every second week = 50%
4 days a week = 60%, etc.
If you need to provide this information about more than two children, please provide the necessary information on a separate
sheet. Be sure to indicate your social insurance number and send the sheet to us with this form. Both you and the other person
must sign the sheet.
4. Declaration and signatures
Making a false declaration is an offence and may result in repercussions against you.
I declare that all the information given in this application is true and complete.
Date
Your signature
year
month
day
month
day
day
Signature of the other person
Date
Note that signing this form does not constitute an application for child assistance payments. If you are not already receiving
child assistance, you must file an application.
If you are unable to obtain the signature of the other person, please indicate the reason:
If the other person has not signed, we will have to make additional verifications with you both, which will prolong the time
needed to process your request.
If this form has been completed by another person, that person must provide the following information:
Family name
Given name
Signed in the capacity of
area code
Telephone
area code
OtherExtension
year
month
day
Date
Signature
We can pay child assistance payments for up to 11 months retroactive to the date the application is received. If, as a result of this
application, we determine that the other person received amounts to which he or she was not entitled, the amounts will be claimed
from that person. We can claim amounts for the preceding 3 years.
For more information
Online
By telephone
Québec region: 418 643-3381
Montréal region: 514 864-3873
Toll-free: 1 800 667-9625
Please return the duly completed form to:
Print
Retraite Québec
Retraite Québec, case postale 7777, Québec (Québec) G1K 7T4
LPF-809A (16-01)