Declaration of overdue amounts owed to provincial governments or the Government of Canada form (Atlantic Fisheries Fund)

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Declaration of overdue amounts owed to provincial governments or the Government of Canada

Recipient name: _________________________      Project number: _________________________

You must complete this form if you have any of the following outstanding or overdue amounts owed to the government(s):

1. amounts due from taxation (including tax assessments), the sale of goods, the provision of services, the use of facilities, and statutory remittances or other obligations, including dividends and transfers of profits and surpluses arising from the government's financial interest in outside organizations;
2. overpayments or erroneous payments of salaries, allowances, supplier accounts, grants, contributions and benefits;
3. disputed claims, at their estimated value;
4. gross amounts assigned to third parties for collection;
5. amounts due from repayable contributions when the conditions that make the contribution repayable have been met;
6. amounts due from defaulted grants or contributions;
7. amounts due from defaulted loans as a consequence of a federal department honouring a loan guarantee;
8. amounts due from penalties, fines and court awards; and
9. interest, penalties or administrative charges on the amounts and items specified above.

I hereby solemnly declare that the above responses are true, 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: _____________________________________________________