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DCI# 1323248 (2014-2015) v2
Privacy Act Statement:
The information you provide in this document is collected under the authority of Contributions to support organizational capacity of representative Aboriginal
organizations for the purpose of building organizational capacity within representative Aboriginal organizations. Information on individuals is used by
Aboriginal Affairs and Northern Development Canada Basic Organizational Capacity Program employees who need to know the information in order to
respond to your request and/or the program requirements. We do not share personal information with other government departments or organizations. The
information will be kept for a period of 30 years. Individuals have the right to the protection of and access to the information provided under the Privacy Act. The information collected is described under the Treasury Board Personal Information Bank INA PPU 300
which is detailed at InfoSource.
Name of Recipient Organization
Reporting Period (YYYYMMDD)
Date Completed (YYYYMMDD)
Program Contact - Given Name
Permanent Address (Number/Street/Apartment/P.O. Box)
Web site (if available)
Indicate the name(s) of supporting document(s) being submitted and the method of submission.
|Name of Supporting Document
||Method of Submission (Attached to Report, E-mail, Facsimile, Mail, By Hand/Courier)
|Add a Document
The information provided on behalf of the recipient is accurate to the best of my knowledge.
Title Date (YYYYMMDD)