Income Assistance Report

PDF Version - Fill & Print (282 Kb, 6 Pages)

Form Instructions

DCI# 455897.GCIMS (2015-2016)

Privacy Act Statement

This statement explains the purposes of the collection and use of 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 personal information for this Income Assistance Sub-Program within Social Development is derived from the Department of Indian Affairs and Northern Development Act, R.S.C., 1985, c. I-6, as well as from annual Appropriation Acts granting authority to the Government to spend funds on programs.

We will use personal information for assessing and determining eligibility for the administration of the program to which you are applying, and for reporting on aggregated results. We share the personal information you give us with those as outlined under AANDC PPU 240 detailed at Info Source.

The information collected will be retained for a period of five years, then sent to Library and Archives Canada. As stated in the Privacy Act, you have the right to access the personal information you give us and request changes to incorrect information.

Contact your regional office to notify us about incorrect information, or contact the AANDC Public Enquiries by phone at 1 (800) 567-9604 for general enquires. For more information on privacy issues and the Privacy Act in general, you can consult the Privacy Commissioner at 1 (800) 282-1376.

Reporting frequency for all parts of the report: Every quarter, four (4) times a year, for ALL recipients, whether under an annual or a multi-year funding arrangement

Recipient Information

1. Recipient Name

2. Recipient Number

3. Reporting Period (YYYYMMDD)

  • From
  • To

4. Region

Part A: Clients and Dependants

5. Clients and Dependants by Educational Attainment, Family Composition, Age and Sex
(including Enhanced Service Delivery Recipients)

  Single(s) Single(s)
with child(ren)
Couple(s) Couple(s)
with child(ren)
Total
Age Education Sex Client Client Dependant Client Dependant Client Dependant  
0-5   male                
female                
6-15   male                
female                
16-17 Did not complete secondary
(high) school diploma
male                
female                
Secondary (high) school diploma or equivalent male                
female                
Post-secondary, apprentice- ship or trades certificate,
diploma or degree from a college/CEGEP or university
male                
female                
18-24 Did not complete secondary
(high) school diploma
male                
female                
Secondary (high) school diploma or equivalent male                
female                
Post-secondary, apprentice- ship or trades certificate, diploma or degree from a college/CEGEP or university male                
female                
25-34 Did not complete secondary
(high) school diploma
male                
female                
Secondary (high) school diploma or equivalent male                
female                
Post-secondary, apprentice- ship or trades certificate, diploma or degree from a college/CEGEP or university male                
female                
35-44 Did not complete secondary
(high) school diploma
male                
female                
Secondary (high) school diploma or equivalent male                
female                
Post-secondary, apprentice- ship or trades certificate, diploma or degree from a college/CEGEP or university male                
female                
45-64 Did not complete secondary
(high) school diploma
male                
female                
Secondary (high) school diploma or equivalent male                
female                
Post-secondary, apprentice- ship or trades certificate, diploma or degree from a college/CEGEP or university male                
female                
65+ Did not complete secondary
(high) school diploma
male                
female                
Secondary (high) school diploma or equivalent male                
female                
Post-secondary, apprentice- ship or trades certificate, diploma or degree from a college/CEGEP or university male                
female                
Total                

6. Clients and Dependants (16+) Who Participated In Active Measures,
by Family Composition, Age and Sex (including Enhanced Service Delivery Recipients)

  Single(s) Single(s)
with child(ren)
Couple(s) Couple(s)
with child(ren)
Total
Age Sex Client Client Dependant Client Dependant Client Dependant  
16-17 male                
female                
18-24 male                
female                
25-34 male                
female                
35-44 male                
female                
45-64 male                
female                
65 + male                
female                
Total                

7. Clients and Dependants (16+) Who Participated In Active Measures With Employment Earnings,
by Family Composition, Age and Sex (including Enhanced Service Delivery Recipients)

  Single(s) Single(s)
with child(ren)
Couple(s) Couple(s)
with child(ren)
Total
Age Sex Client Client Dependant Client Dependant Client Dependant  
16-17 male                
female                
18-24 male                
female                
25-34 male                
female                
35-44 male                
female                
45-64 male                
female                
65 + male                
female                
Total                
Total Amount of Employment Earnings:  

8. Clients and Dependants (16+) Who Exited to Employment or Education,
by Family Composition, Age and Sex (including Enhanced Service Delivery Recipients)

  Single(s) Single(s)
with child(ren)
Couple(s) Couple(s)
with child(ren)
Total
Age Exits Sex Client Client Dependant Client Dependant Client Dependant  
16-17 Exited to employment male                
female                
Exited to education male                
female                
Other reasons male                
female                
18-24 Exited to employment male                
female                
Exited to education male                
female                
Other reasons male                
female                
25-34 Exited to employment male                
female                
Exited to education male                
female                
Other reasons male                
female                
35-44 Exited to employment male                
female                
Exited to education male                
female                
Other reasons male                
female                
45-64 Exited to employment male                
female                
Exited to education male                
female                
Other reasons male                
female                
65 + Exited to employment male                
female                
Exited to education male                
female                
Other reasons male                
female                
Total                

9. Service Delivery (Including Enhanced Service Delivery Recipients)

Clients have access to Case Management (refer to definition of Case Management in the Instructions)

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

Part B: Financial Management Report

10. Income Assistance Expenditures

  Total Amount ($)
a) Basic Needs (including food, clothing, shelter, fuel, etc.)  
b) Special Needs  
c) Service Delivery  
d) Employment and Training (excluding Enhanced Service Delivery)  
Total  

11. 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    

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  

12. Children Out of Parental Home (COPH)

  Total Number of Children Total Amounts ($)
Total    

13. National Child Benefit Supplement (NCBS) Tracking - NCBS-eligible Provinces/Territories

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

Part C: Recipients Under Enhanced Service Delivery (ESD) Only

14. Number of New Caseworkers
(Recipients under Enhanced Service Delivery Only)

Total Number of New Caseworker Positions:

15. Clients and Dependants That Are Being Case Managed,
by Age and Sex (Recipients under Enhanced Service Delivery Only)

  Age 18-24  
  Male Female Total
New clients and dependants only that are being case managed      
Total clients and dependants that are being case managed      

16. Clients and Dependants That Were Referred to First Nations Job Fund (FNJF) or Other Programs For Job Skills Training, by Age and Sex (Recipients under Enhanced Service Delivery Only)

  Age 18-24  
  Male Female Total
a) Referred to FNJF only      
b) Referred to other programs for job skills training (not FNJF)      
c) Referred to other services (see Instructions)      
Total      

17. Clients and Dependants Under Enhanced Service Delivery Who Did Not Meet Employability Criteria,
by Age and Sex
(Recipients under Enhanced Service Delivery Only)

  Age 18-24
  Male Female
     
Total  

18. Clients and Dependants Who Exited Enhanced Service Delivery to Employment or Education,
by Age and Sex (Recipients under Enhanced Service Delivery Only)

  Age 18-24  
  Male Female Total
a) Exited to employment      
b) Exited to education      
c) Other reasons (see Instructions)      
Total      

19. Enhanced Service Delivery Expenditures
(Recipients under Enhanced Service Delivery Only)

  Total Amount ($)
a) Case Management Capacity  
b) Client Support  
c) Service Delivery Infrastructure Support  

Declaration:

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

Given Name

Family Name

Title

Date (YYYYMMDD)