Band Employee Benefits Report

PDF Version - Fill & Print (139 Kb, 1 Page)

Form Instructions

DCI# 41784.GCIMS (2015-2016)

Privacy Act Statement:

This statement explains the purposes and use of your personal information. 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.

The collection and use of your personal information for this application for the Band Employee Benefits program is authorized by s. 4 of the Department of Indian Affairs and Northern Development Act, R.S.C., 1985, c. I-6, for administrative purposes and is required for your participation.

Your information will be used by the Indian Government Support program employees in order to respond to your request (s) and/or program requirements. We do not share the personal information with other government departments. This information is described in Personal Information Bank AANDC PPU 300 and will be retained for a period of 30 years and then the records are transferred to the Library and Archives Canada for archival purposes.

As stated in the Privacy Act, you have the right to access your personal information and request changes to incorrect information. Contact program staff by email at DPI-PID@aadnc-aandc.gc.ca or call 1 (800) 567-9604 to notify us of incorrect information. For more information on privacy issues and the Privacy Act in general, you can consult the Privacy Commissioner at 1 (800) 282-1376.

Recipient Name

Recipient Number

Region

List of Eligible Employees

Employer Name

Period (YYYYMMDD)

From

To

            Total Dollar Contribution
Employee Given Name Employee
Family Name
Occupation Program Source of Salary Salary $ Pension
Plan
Employee $
Pension
Plan
Employer $
CPP/QPP
Plan
Employee $
CPP/QPP
Plan
Employer $
Group
Insurance
Employee $
Group
Insurance
Employer $
                       
                       
Totals              

I am hereby reporting on Band Employee Benefits funding. The information provided in this report is, to the best of my knowledge, true and accurate.

Given Name
Family Name
Title
Telephone Number
Email Address
Date(YYYYMMDD)