Contribution Funds for Non-governmental Organizations - a Handbook

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APPENDIX A: PA-1 FORM

DEPARTMENT OF JUSTICE CANADA
STATEMENT OF REVENUES AND EXPENDITURES
FINAL CLAIM

• File No:
• Recipient Name:
• Period of Agreement:
• Period of Report: from: to:

	JUSTICE CANADA ELIGIBLE APPROVED COSTS	TOTAL ACTUAL PROJECT EXPENSES & REVENUES	IF REQUIRED AS PER THE AGREEMENT, PLEASE PROVIDE EXPLANATIONS FOR THE VARIANCE IN EXCESS OF 20% OF THE BUDGETED ITEMS
REVENUES
Department of Justice Canada	$0
TOTAL REVENUES	$0	$0
EXPENDITURES
TOTAL EXPENDITURES	$0	$0

• Signature:
  (Signed by an authorized representative from the organization)
• Date:
• Title(please print title):
• Telephone:
• Recipients E-mail address:
• JUS/PA-1 (rev. 10/2010)

Please report all revenues and expenditures stated in the contribution agreement budget and incurred within the specific period of the agreement.

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

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