Contribution Funds for Non-governmental Organizations - a Handbook

Appendix B: PA-4 Form

Department of Justice Canada
Statement of Revenues and Expenditures
Request for Interim Payment

File No:

Fund Name:

Recipient Name:

Period of Agreement:

Period of Report: from: to:

  Justice Canada Eligible Approved Costs Actual
Expenses &
Revenues
from
dd / mm / yyyy
to
dd / mm / yyyy
 Projected
Expenses
from
dd / mm / yyyy
to
dd / mm / yyyy
Revenues
Department of Justice Canada      
Total Revenues $0 $0 $0
Expenditures
       
Total Expenditures $0 $0 $0

I hereby confirm that the amounts reported in this claim are in compliance with the terms and conditions of the Agreement. I acknowledge that this final claim has been ajusted for any GST/HST rebates, if applicable.

Signature:
(Signed by an authorized representative from the organization)

Date:

Title (please print title):

Telephone:

Recipients E-mail address:

JUS/PA-4 (rev. 3/2015)

** Please report all cumulative revenues and expenditures from the start of the project to date.

The section highlighted in grey is for Justice Canada's use only. Please do not modify or change this area.