Canada 150 Community Infrastructure Program - Claim Statement


The purpose of the Claim Statement is to list eligible and supported costs that you have incurred and paid and would like to claim for reimbursement.

To complete the Claim Statement, please download the MS Excel file provided. Once you have downloaded the file, refer to the Claims Submission Process for step-by-step instructions on how to complete and submit the form.

Text from the sheet including some examples may be found below.

Fillable Excel version

Section 1

Project Information
Recipient Name:
Project Number:
Program: Canada 150 Community Infrastructure Program
Project Title:

Section 2

Claim Information
Claim period:
Date Claim Prepared:
Contact Name:
Contact Phone/E-mail:

Section 3

New Invoices – List only Supported Eligible Costs claimed to Contribution Agreement
Invoice #
Invoice Date
Project Cost Category per Contribution Agreement (See Annex 1: Project Costs & Financing)
Vendor Name
Work Description
Invoice Amount
HST Rebate
Net Claim Amount
Cheque #

(Federal use only) Totals

Section 4

Cost Category Summary (Federal Use Only)
Please ensure this matches your records.  Adjustments  Net Claim
Project Management

Cost Category Total:

HST recovery rate:

Date modified: