Identification and certification, detailed costs claimed and progress report
Quebec Fisheries Fund

Identification and certification

Recipient name ________________________________ Project number ________________________________

Contact name ________________________________ Payment number ________________________________

Period covered: From ________________ To ________________

Is this your final claim? (If yes, submit final payment certificate) Yes  No

Contact information

Has your mailing address, email, telephone number changed?  Yes  No

If yes, please provide new information below

Do you have a QST/GST registration number?  Yes  No

QST/GST registration number ________________

If yes, please provide the refundable QST rate applicable to the costs claimed (100%; 67%; 50%, etc.) ______ %

Provide the refundable GST rate applicable to the costs claimed (100%; 67%; 50%, etc.) ______ %

Certification by the recipient

I hereby certify that:

1. the costs being claimed have been incurred and are eligible.  Yes  No
2. all goods and/or services for claimed costs have been received.  Yes  No
3. the information provided is accurate and complete.  Yes  No
4. the recipient is in compliance with all terms and conditions of the contribution agreement.  Yes  No
5. any payment received as a result of this and all previous claims will be applied to eligible costs. Yes  No
6. any funding received from federal, provincial or municipal governments is the same as stated on the statement of work of the contribution agreement.
    Yes  No
7. the costs being claimed are all at arm's-length (i.e. no common ownership, no family ties).  Yes  No
8. adjustments to costs previously claimed (e.g. returns, credits, rebates) have been reported in the detailed costs claimed section.  N/A  Yes  No
   If you have certified no for any of statements a) to h), provide details in the following section:
   (If more space is required, provide additional details in separate attachment.)
   Item number ________________________________ Comments ________________________________
9. the recipient has overdue amounts owed to the Government of Canada (e.g. remittances for employee deductions, GST, income tax). (If yes, submit the declaration of overdue amounts owed to the Government of Canada form)  Yes  No

Costs claimed and paid by the recipient

1. Total amount claimed in previous claim(s) (if first claim, enter $0.00)
   Claimed to QFF: ________________ Paid to supplier / employee: ________________
2. Total amount claimed in this claim from the detailed costs claimed form(s)
   Claimed to QFF: ________________ Paid to supplier / employee: ________________
3. Total amount claimed to date (1+2)
   Claimed to QFF: ________________ Paid to supplier / employee: ________________

I hereby solemnly declare that the responses above and on the detailed costs claimed and progress report section 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.

Person authorized to sign on behalf of the recipient

Signature ________________________________ Date ________________ Print name and title ________________________________

Detailed costs claimed

Progress report

1. Is the project progressing in scope, time frame and budget as defined in the statement of work?  Yes  No
   Provide a short narrative on the status of the project. (e.g. timing, costs incurred, tasks and activities undertaken, and any challenges encountered
   
   Note: Please ensure that you have provided sufficient details to meet the reporting requirements specified in your contribution agreement. Attach a separate report if warranted.
2. Indicate the approximate timing and the estimated amount of your future claim(s).
   Month ________________ Year ________________ Eligible costs ________________
3. As described in your statement of work, please provide information on the expected project results that have been achieved:
   Expected project results
   
   Progress to date
   

Additional comments:

For final progress report

4. Is this your final progress report?  Yes  No
   (If yes, please ensure you fulfil any final reporting requirements as described in your contribution agreement. Attach a separate report if warranted.)