ARCHIVED - Child and Family Services Maintenance Report

Archived information

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Form Instructions

DCI# 455917 (2014-2015)

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 Child and Family Services Program employees on a "need to know basis" for program administration purposes. As a general rule, we do not share personal information with other federal government departments. However, in exceptional circumstances, case specific information may be disclosed to Health Canada and/or the province/territory under whose jurisdiction the child has been taken into care. In some cases, information may be disclosed without your consent for purposes not outlined in the statement pursuant to subsection 8(2) of the Privacy Act. The personal information will be kept for a period of 5 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 Treasury Board Personal Information Bank First Nations Child and Family Services AANDC PPU 210 which is detailed at InfoSource.

Province or Territory

Agency Name

Funding Recipient Number

Fiscal Year

Funding Recipient Name (Agreement)

Type of Submission (Original, Re-submission, Supplemental, Amendment)

Reporting Period (January, February, March, April, May, June, July, August, September, October, November, December, April-June, July-September, October-December, January-March)

IRS Number Non-Registered
Temp. No.
Child's Family Name Child's Given Name Date of Birth Gender (M, F, NR)
Add Child            

Financial Summary for DCI

Placement Type / Service Total Number of Child Placements Total Number of Days Total Care Cost Total Additional Child Expenses Total Maintenance Cost
Foster Homes         $0.00
Group Homes         $0.00
Institutional Care         $0.00
Kinship Care         $0.00
Post Adoption Subsidy         $0.00

Children and Family Services Prevention Activities

Individuals and Families
Number of Children 0
Number of Families 0


Groups and Communities
Number of Sessions 0
Number of Participants 0

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

Given (First) Name Family (Last) Name Title Date


Date modified: