Band Employee Benefits Report

PDF Version - Fill & Print (95 Kb, 1 Page)

Form Instructions

DCI# 41784 (2014-2015)

Privacy Act Statement:

Information you provide in this document is collected under the authority of the Indian Government Support program policies for administrative purposes. Information on individuals is used by Aboriginal Affairs and Northern Development Canada's Indian Government Support program employees who need to know the information in order to respond to your request and/or the program requirements. We do not share the personal information with other government departments. The personal information will be kept for a period of 7 years. Individuals have the right to the protection of and access to their personal information under the Privacy Act. The information collected is described under the Treasury Board Personal Information Bank INA LTS 401 which is detailed at InfoSource.

Recipient Name

Recipient Number

Region

List of Eligible Employees

Employer Name

Period (YYYYMMDD)

From

To

            Total Dollar Contribution
Employee Given Name Employee
Family Name
Occupation Program Source of Salary Salary $ Pension
Plan
Employee $
Pension
Plan
Employer $
CPP/QPP
Plan
Employee $
CPP/QPP
Plan
Employer $
Group
Insurance
Employee $
Group
Insurance
Employer $
                       
                       
Totals              

I am hereby reporting on Band Employee Benefits funding. The information provided in this report is, to the best of my knowledge, true and accurate.

Given Name
Family Name
Title
Telephone Number
Email Address
Date(YYYYMMDD)