PAW 84458230 (2021-2022)
Page 1 of 2
PROTECTED A (When Completed)
INDIGENOUS COMMUNITY SUPPORT FUND PROPOSAL
Privacy Statement
This statement explains the purposes for the collection and use of personal information. Only information needed to respond to program/reporting
requirements will be requested. Collection and use of personal information are in accordance with the Privacy Act (https://laws-lois.justice.gc.ca/eng/acts/
P-21/index.html). In some cases, information may be disclosed without your consent pursuant to subsection 8(2) of the Privacy Act. We will use your
personal information in order to respond to your requests and/or program requirements. The collection and use of your personal information provided to
Indigenous Services Canada for selected program/funding reporting and administration purposes are authorized by program specific legislation and
required for your participation. The information collected is described by program specific Personal Information Banks (PIB) detailed at Info Source (https://
www.aadnc-aandc.gc.ca/eng/1353081939455/1353082011520). For further details about applicable legislative authority, PIB description and/or to notify us
about incorrect information or to withdraw participation after submitting your information, contact the departmental Public Enquiries Contact Centre at
1-800-567-9604. If you require clarification about this statement, contact our Privacy Coordinator at 819-997-8277. For more information on privacy issues
and the Privacy Act in general, you may consult the Privacy Commissioner at 1-800-282-1376.
Identification
Recipient Name
Recipient Number
Region
Beneficiary
First Nation Inuit Métis Urban/Off-Reserve Indigenous Organizations and Communities
Contact
Given Name Family Name
Mailing Address (Number/Street/Apartment/P.O. Box)
City/Town
Province/Territory
Postal Code
Telephone Number Facsimile Number Email Address
Application Information
Proposal Title
Proposal Summary
Activities
Perimeter Security Medical Supplies
Installation of Physical
Barriers
Food Security
Transportation Cleaning Supplies Incremental Staff Costs Lodging and Accommodation
Infrastructure Mental Wellness Support Cultural Supports Seniors Support
Child and Family Supports Online Learning Supports
Communication of
Information
Other
If Other, Specify
Is this funding part of a pandemic plan? Yes No
PAW 84458230 (2021-2022)
Page 2 of 2
PROTECTED A (When Completed)
Budget Summary
Budget Item Description Priority
Rate or
Cost ($)
Unit Quantity Cash Total ($)
Total Requested Amount ($)
Partners
Will partners be involved? Yes No
Partner Name Involvement Contact Name
Telephone
Number
Email Address (if applicable)
Other Governmental Funding
Have you received or requested any other governmental funding (e.g. federal, provincial, territorial, municipal) to address this need?
Yes No
Source
Outcome Amount
Supporting Documents (if applicable)
This table allows you to identify the supporting documents being submitted and the method of submission.
Title Submission Method
Declaration
The information provided is accurate to the best of my knowledge.
Given Name Family Name
Title
Date (YYYYMMDD)
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