ARCHIVED - Report on Activities and Expenditures

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Form Instructions

DCI# 4548549 (2014-2015)

Privacy Act Statement

This statement explains the purposes of collecting your personal information and how it is used. Only information needed to respond to program requirements will be requested. Collection and use of personal information is in accordance with the Privacy Act. In some cases, information may be disclosed without your consent pursuant to subsection 8(2) of the Privacy Act.

Contact your regional office or program contact for information on the authority under which your personal information is collected and used.

We will use your personal information as assurance that the information contained in the form is accurate or to contact you about information contained in the form. We do not share the personal information you give us. The information collected is described in the Program Administration Class of Personal Information detailed at Info Source. Contact your regional office or program contact for information on the retention and disposition of your personal information.

As stated in the Privacy Act, you have the right to access your personal information and request changes to incorrect information. Contact your regional office or program
contact to notify us about incorrect information.

RECIPIENT IDENTIFICATION

Recipient Name
Recipient Number

PROGRAM IDENTIFICATION

Choose the program on which you are reporting from the list below. Selecting a program hides the fields that are not required for that program.

PROJECT INFORMATION

Project Name
Project Number

ATTACHMENTS

There are two options available to complete this form: you may enter the information directly on the form, or you may complete the Recipient Identification and Program Identification sections and attach a document containing the information required for the program you have selected.

Additionally, any deliverables specified in the recipient's funding agreement should be attached if completed.

Name of document

Method of Submission

ACTIVITY REPORT

Period
Date From (YYYY-MM-DD)
Date To (YYYY-MM-DD)

ACTIVITY

PROGRAM PERFORMANCE INDICATORS

ecoENERGY for Aboriginal and Northern Communities Program

If this is a final report, describe the current stage of the project based on the work activities completed, the project next steps, and the anticipated construction/operation date of the project.

Identify any aspects of the project that have changed that may affect the estimated greenhouse gas emissions reductions of the project

EXPENDITURE REPORT

Period
Date From (YYYY-MM-DD)
Date To (YYYY-MM-DD)

Budget Item
Budget Amount
Expenditure Amount
Variance
Total

In-Kind Sources (if applicable)
Source Name
Value (Optional)
Total In-Kind Sources

DECLARATION

The information provided is accurate to the best of my knowledge

Given Name
Family Name
Title
Date (YYYY-MM-DD)

CONTACT INFORMATION

Enter the contact information for the individual(s) responsible for completing this form.

Contact
Given Name
Family Name
Title/Position
Telephone Number
Extension Number
Fax Number
Email
Mailing Address (Number/Street/Apartment/P.O. Box)
City/Town
Province or Territory
Postal Code

If you require an alternate format, please email us at: Formulaire.Forms@aadnc-aandc.gc.ca

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