ARCHIVED - Assisted Living Report
This Web page has been archived on the Web. Archived information is provided for reference, research or record keeping purposes. It is not subject to the Government of Canada Web Standards and has not been altered or updated since it was archived. Please contact us to request a format other than those available.
PDF Version - Fill & Print (157 Kb, 1 Page)
DCI# 455937 (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 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. However, in exceptional circumstances, case specific information may be discussed with Health Canada and/or the province/territory under whose jurisdiction the recipient may fall. 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 502 which is detailed at InfoSource.
Reporting Period (YYYYMMDD)
|Sex||Date of Birth
|Name of Institution or Foster Care Home (if applicable)||Parent/
Given Name /
|Assessment Date (YYYY
of Service Need Assessed
Start Date (YYYY
End Date (YYYY
|Rate Unit||Total Number of Units||Total ($)|
The information provided is accurate to the best of my knowledge.
- Date modified: