Language selection

Government of Canada / Gouvernement du Canada

Search

Identification and certification, detailed costs claimed, and progress report form (Atlantic Fisheries Fund)

To fill out a PDF form, you must:

  1. download it to your computer
  2. use PDF software to open it (such as, Adobe Reader or Foxit PDF)

For more information: How to download and open a PDF form

 Download form
Identification and certification
Identification and certification
Recipient name:   Project number: (AFF-province-project #)
Contact name:   Your claim number:  
Period covered: From: Is this your final claim? (If yes, submit final payment certificate) Yes No

To:
Contact information: Has your mailing address, email, telephone number changed?
(If yes, please provide new information below)
 
Certification by the recipient
I hereby certify that: Yes No
a) the costs being claimed have been incurred and are eligible as per the contribution agreement.
b) all goods and/or services for claimed costs have been received.
c) the Recipient is in compliance with and following all the terms and conditions of the Contribution Agreement.
d) any payment received from the Atlantic Fisheries Fund as a result of this and all previous claims will be applied to eligible costs.
e) the costs being claimed are from a non-related third party (no common ownership, or no family ties).
f) adjustments to costs previously claimed (e.g. returns, credits, rebates) have been reported in the detailed costs claimed form.

If you have certified no for any of statements a) to f), provide details in the following section:
(If more space is required, provide additional details in separate attachment.)
  Yes No
g) the Recipient has overdue amounts owed to the Government (e.g. remittances for employee deductions, HST/GST, income tax)
(If yes, submit the declaration of overdue amounts owed to the Government form)
h) the Recipient, a not-for-profit entity, has received an eligible non-cash contribution toward the project during this claim period
(If yes, submit the non-cash costs certification form) 		N/A
Costs claimed and paid by the recipient
Costs claimed and paid by the recipient
  Claimed to AFF Paid to supplier / employee
1) Total amount claimed in this claim from the detailed costs claimed form(s)    
I hereby solemnly declare that the responses above and on the detailed costs claimed and progress report forms are true, accurate and complete, knowing that this declaration is of the same force and effect as if made under oath and by virtue of the Canada Evidence Act.
Recipient or person authorized to sign on behalf of the recipient
Signature:   Date:  
Print name and title:  
Detailed costs claimed
Detailed costs claimed
Recipient name:   Project number:   Payment number:   Page included in claim page: none of none
Category per eligible cost
(Group costs as listed in the statement of work)		 Description of eligible cost incurred Paid or payable to
(Name of supplier or employee)		 Invoice no.
(Or supporting document no.)		 Invoice date
(YYYY/MM/DD)		 Invoice
amount
(Incl. full HST/GST)		 Amount of invoice paid to date Amount of HST/GST
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
Total this page      
Less: HST/GST total from this page ______X HST/GST refundable rate ______% = refundable HST/GST ( ______ )
Amount claimed on this page (excluding HST above)  
Total amount claimed on previous page(s) (If any in this claim)  
(Put this amount on line 1 of the identification certification page) Total amount claimed  
Progress report

Progress report
Recipient name:   Project number:  
      Yes No

1. Is the project progressing as planned and on budget as per the statement of work?

Please provide an update (e.g. timing, costs incurred, tasks/work and activities started/completed and any challenges/issues encountered) on the progress of the project.

 

 

 

Note: Please ensure that you have provided enough details to meet the reporting requirements and expected results progress as required in your contribution agreement. Attach a separate report if needed.
2. Indicate the approximate timing and the estimated amount of your future project claim(s).
Month Year Eligible costs
     
     
     
     
     
For final progress report
  Yes No

3. Is this your final progress report? (If yes, please submit a completed final payment certificate)
Date modified: