ARCHIVED - Child and Family Services Maintenance Report (2015-2016)

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Form Instructions

DCI# 455917.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 First Nations Child and Family Services Sub- Program within Social Development is derived from the Department of Indian Affairs and Northern Development Act, R.S.C., 1985, c. I-6, and from annual Appropriation Acts granting authority to the Government to spend funds on programs.

We will use personal information to assess and determine service provider's eligibility to administer the program, and for reporting on aggregated results. We share the personal information you give us with those as outlined in the AANDC PPU 210 detailed at Info Source. The information collected will be retained for 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, or contact the AANDC Public Enquiries by phone at 1 (800) 567-9604 for general enquires. Contact your regional office to notify us about 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.

Province or Territory

Agency Name

Funding Recipient Number

Fiscal Year (2015-2016)

Funding Recipient Name (Agreement)

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

Reporting Period (APRIL 1 – APRIL 30, MAY 1 – MAY 31, JUNE 1 – JUNE 30, JULY 1 – JULY 31, AUGUST 1 – AUGUST 31, SEPTEMBER 1 – SEPTEMBER 30, OCTOBER 1 – OCTOBER 31, NOVEMBER 1 – NOVEMBER 30, DECEMBER 1 – DECEMBER 31, JANUARY 1 – JANUARY 31, FEBRUARY 1 – FEBRUARY 29, MARCH 1 – MARCH 31, APRIL 1 – JUNE 30, JULY 1 – SEPEMBER 30, OCTOBER 1 – DECEMBER 31, JANUARY 1 – MARCH 31)

Child # 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          
Group Homes          
Institutional Care          
Kinship Care          
Post Adoption Subsidy          

Children and Family Services Prevention Activities

Individuals and Families
Number of Children  
Number of Families  
Groups and Communities
Number of Sessions  
Number of Participants  

Authorization

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

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

Contact

Given (First) Name

Family (Last) Name

Title

Telephone Number

Email Address

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