Income Assistance Report

PDF Version - Fill & Print (248 Kb, 7 Pages)

Form Instructions

DCI# 455897 (2014–2015) v2

Privacy Act Statement

The information you provide in this document is collected under the authority of the Department of Indian Affairs and Northern Development Act for the purpose of assessing performance, allocating funds, and in determining, if applicable, eligibility for reimbursement. Information on individuals is used by Aboriginal Affairs and Northern Development Canada's Income Assistance 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 federal government departments. The personal information will be kept for a period of five years after which it will be sent to archives. 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 Personal Information Bank INA SEP 504 which is detailed at InfoSource.

Recipient Information

1. Recipient Name

2. Recipient Number

3. Reporting Period (YYYYMMDD)

Start Date

End Date

4. Region

Part A

Frequency: Every quarter, four times a year, for all First Nations, whether under an annual or a multi-year funding agreement

5. Family Composition (Age and Gender)

Single
  0-5 6-15 16-17 18-24 25-44 45-64 65+ Total Number
Clients Male                
Female                
Total                

Single Parent (With Child(ren))
  0-5 6-15 16-17 18-24 25-44 45-64 65+ Total Number
Clients Male                
Female                
Dependants Male                
Female                
Total                

Couples (Without Child(ren))
  0-5 6-15 16-17 18-24 25-44 45-64 65+ Total Number
Clients Male                
Female                
Dependants Male                
Female                
Total                

Couples With Child(ren)
  0-5 6-15 16-17 18-24 25-44 45-64 65+ Total Number
Clients Male                
Female                
Dependants Male                
Female                
Total                

6. Service Delivery

Clients have access to Case Management process

  • Yes
  • No
  • If "Yes":
    1. Case Management is accessed by clients directly through the Band/First Nation organization
    2. Case Management is accessed by clients outside of the Band/First Nation organization through another organization (e.g., ASETS holder, employment centre) with a formal shared service agreement. Please specify the name of the organization below:
    3. Case Management is accessed by clients outside of the Band/First Nation organization through  another organization (e.g., ASETS holder, employment centre) without a formal shared service agreement. Please specify the name of the organization below:

7. Education Attainment and Gender of Clients Who Are Expected to Work and Not Expected to Work

  Number of Clients
Expected to Work Not Expected to Work
Male Female Male Female
a) Did not complete high school (or grade 12)        
b) High school diploma (or grade 12) equivalent        
c) Post-secondary, apprenticeship or trades certificate, diploma or degree from a college or university (e.g. CEGEP)        
Total        

8. Age and Gender of Clients and Dependants (16+) Expected to Work and Not Expected to Work

  Expected to Work Not Expected to Work Total Number
Male Female Male Female
a) Clients          
b) Dependants (+16)          
Total          

9. Number of Clients and Dependants (16+) Who Participated in Active Measures

A. Participated in Employment or Pre-employment Activities Total Number
a) Employment/Pre-employment (e.g. job shadowing, internship)  
b) Skills training  
c) Basic Literacy and Essential Skills training  
d) Adult Education (e.g. Adult Basic Education, General Educational Development)  
e) Voluntary work opportunity  
f) Career and job seeking skills counseling (e.g. career assessment)  
g) Pre-employment and employment supports (e.g. Child Care, WOP, Wage Subsidy)  
h) Other items identified in the reference province/territorial legislation  
Total  

B. Received Employment or Pre-employment Financial Supports Total Number
a) Training allowance  
b) Wage subsidy  
c) Transportation  
d) Equipment  
e) Child care  
f) Employment-related relocation costs  
g) Accommodation  
h) Transfers to employers, other institutions and governments for training and employment services  
i) Other items identified in the reference province/territorial legislation  
j) Other  (Specify)  
Total  

10. Age and Gender of Clients and Dependents (16+) Who Participated in Active Measures

  16-17 18-24 25-44 45-64 Total Number
Male Female Male Female Male Female Male Female
                   
Total                  

11. Employment Earnings of Clients and Dependents (16+) Who Participated in Active Measures

a) Total Number of Clients Who Participated in Active Measures with Employment Earnings
  16-17 18-24 25-44 45-64 Total Number
Male Female Male Female Male Female Male Female
                   
Total                  

b) Amount($) of Employment Earnings - Total Amount ($)

12. Clients and Dependents (16+) Who Exited to Employment or Education

  16-17 18-24 25-44 45-64 Total Number
Male Female Male Female Male Female Male Female
a) Exited to Employment                  
b) Exited to Education                  
c) Unable to Track                  
Total                  

13. Partnership for Active Measures Activities (Select all that apply)

  1. Employment and Social Development Canada (ESDC) (formerly known as HRSDC)
  2. Health Canada
  3. Other Federal Government Department(s)
  4. Provincial or Territorial Government e) Private Sector
  5. First Nation Organization(s)
  6. Other (Specify)

Part B

Frequency: Risk based in accordance with the schedule of reporting requirements contained in the agreement

14. Income Assistance Expenditures

  Total Amount ($)
a) Basic Needs  
b) Special Needs  
c) Employment and Training (excluding Enhanced Service Delivery)  
Total  

15. Shelter Information

i) Clients and Expenditures Total Number of Clients Total Amount ($)
a) Number of clients who receive Shelter Allowance (rent, fuel/utilities)  and total related expenditures    
b) Number of clients who receive only fuel/utilities and total related expenditures    
Total    

ii) Housing Units Total Number of Units
c) Number of housing units occupied by Income Assistance clients  
d) Number of housing units occupied by Income Assistance clients for which only fuel/utilities costs were paid  
e) Number of housing units occupied by Income Assistance clients for which fuel/utilities costs and rent were paid  
Total  

16. Children Out of Parental Home (COPH)

  Total Number of Children Total Amount($)
Total    

Part C: Recipients Under Enhanced Service Delivery Only

Frequency: Every quarter, four times a year,  for all First Nations, whether under an annual or a multi-year funding agreement

17. Number of Case Workers

The number of new caseworkers positions - Total Number

18. Age and Gender of Clients That Are Being Case Managed

  16-17 18-24 25-44 45-64 Total Number
Male Female Male Female Male Female Male Female
                   
Total                  

19. Age and Gender of Clients That Were Referred to First Nations Job Fund

  18-24
Male Female
     
Total    

20. Age and Gender of Clients Under Enhanced Service Delivery Who Did Not Meet Employability Criteria

  18-24
Male Female
     
Total    

21. Clients Who Exited Enhanced Service Delivery to Employment or Education

  18-24 Total Number
Male Female
a) Exited to Employment      
b) Exited to Education      
c) Unable to Track      
Total      

22. Enhanced Service Delivery Expenditures

  Total Amount ($)
a) Case Management Capacity  
b) Client Support  
c) Service Delivery Infrastructure Support  
d) Ontario Works- Employment Assistance  

Part D

Frequency: Every quarter, four times a year, for all First Nations, whether under an annual or a multi-year funding agreement

23. National Child Benefit Supplement (NCBS) Tracking - NCBS-Eligible Provinces/Territories

  Total Number of Children Total NCBS Amounts($)
NCBS Quarterly Tracking    

Approval Block (Applicable to the entire form)

The information provided is accurate to the best of my knowledge.

Given Name

Family Name

Title

Date (YYYYMMDD)