Form C (GAC-AMC2572) "Contribution Agreement Final Financial Report" - Canada (English/French)

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Purchase Order
Contribution Agreement
Project Number
Specific Terms and Conditions - Reporting Form
Final Financial Report (Form C)
Year(s) covered
Project Title
Name of Organization
Project completion date (yyyy-mm-dd)
Notes:
1. Line items shall be listed and broken down as detailed in the Project Budget in the Contribution Agreement.
2. If amended, use the budget officially approved through either a signed amendment or an exchange of letters.
3. Significant variances (+/- 10% or approved % in the Agreement) shall be explained in the Final Narrative Report.
DFATD contribution
Organization contribution
Original
Final actual
Variance
Variance
Actual contribution
Line Item Breakdown
Agreement budget
cost
from budget
from budget
(see note 2)
(see note 3)
(note 3)
$
%
Cash
In-Kind
(A)
(B)
(C = A - B)
(D = C ÷ A)
1
TOTAL
Total cumulative interest
1) Declaration of amounts due to Her Majesty:
For the purposes of this Contribution Agreement, the Organization declares, through its
signature below, that it owes to Her Majesty, including to the Department, the amount of:
$CDN.
The Organization agrees that any amounts payable to the Organization may be used to set-off amounts due to Her Majesty.
2) Declaration of all Sources of Project Funding:
The Organization declares, through its signature below, that all sources of funding for the Project just completed have been accurately reflected to the best of the Organization’s knowledge in the final
Project accounting presented above.
Page 1 of 2
GAC-AMC 2572E (2019-05-16)
Purchase Order
Contribution Agreement
Project Number
Specific Terms and Conditions - Reporting Form
Final Financial Report (Form C)
Year(s) covered
Project Title
Name of Organization
Project completion date (yyyy-mm-dd)
Notes:
1. Line items shall be listed and broken down as detailed in the Project Budget in the Contribution Agreement.
2. If amended, use the budget officially approved through either a signed amendment or an exchange of letters.
3. Significant variances (+/- 10% or approved % in the Agreement) shall be explained in the Final Narrative Report.
DFATD contribution
Organization contribution
Original
Final actual
Variance
Variance
Actual contribution
Line Item Breakdown
Agreement budget
cost
from budget
from budget
(see note 2)
(see note 3)
(note 3)
$
%
Cash
In-Kind
(A)
(B)
(C = A - B)
(D = C ÷ A)
1
TOTAL
Total cumulative interest
1) Declaration of amounts due to Her Majesty:
For the purposes of this Contribution Agreement, the Organization declares, through its
signature below, that it owes to Her Majesty, including to the Department, the amount of:
$CDN.
The Organization agrees that any amounts payable to the Organization may be used to set-off amounts due to Her Majesty.
2) Declaration of all Sources of Project Funding:
The Organization declares, through its signature below, that all sources of funding for the Project just completed have been accurately reflected to the best of the Organization’s knowledge in the final
Project accounting presented above.
Page 1 of 2
GAC-AMC 2572E (2019-05-16)
Organization’s Representative: Chief Financial Officer or most senior executive responsible for the finances of the Organization or an official
delegate within the Organization holding a professional designation
I hereby attest that the financial information in this report represents the actual Eligible Costs, and where required, the forecasted amounts, which are in compliance with the terms and conditions of the
Agreement.
Name of Representative
Title of Representative
Signature
Date (yyyy-mm-dd)
Page 2 of 2
GAC-AMC 2572E (2019-05-16)
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