Contribution Funds for Non-governmental Organizations - a Handbook

Appendix A: PA-1 Form

Department of Justice Canada
Statement of Revenues and Expenditures
Final Claim

File No:

Fund Name:

Recipient Name:

Period of Agreement:

Period of Report: from: to:

  Justice Canada Eligible Approved Costs Total Actual Project Expenses & Revenues
Revenues
Department of Justice Canada   $0  

Total Revenues

$0 $0
Expenditures
     
Total Expenditures $0 $0

I hereby confirm that the amounts reported in this claim are in compliance with the terms and conditions of the Agreement.

I acknowledge that this final claim has been adjusted for any GST/HST rebates, if applicable.

Signature:
(Signed by an authorized representative from the organization)

Date:

Title (please print title):

Telephone:

Recipients E-mail address:

JUS/PA-1 (rev. 3/2015)

Please report all revenues and expenditures stated in the contribution agreement budget and incurred within the specific period of the agreement.

The section highlighted in grey is for Justice Canada's use only. Please do not modify or change this area.

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