Indian and Northern Affairs Canada

Affaires indiennes et du Nord Canada

I, am the prospector who signed the application for Prospectors Assistance dated the day of 19 .

Je, suis le signataire de la demande d’aide aux prospecteurs du jour de 19 .

Total months / Total des mois

Cost 1 month / Coût 1 mois $

Total food costs / Coût total de la nourriture $

I purchased the following equipment at the following prices:

Frais d’équipement (préciser le matériel acheté):

I spent the following sums as travelling expenses on the following trips:

Frais de déplacement (donner des précisions sur les déplacements):

In addition I have incurred the following expenses (such as rental of equipment, fuel, explosives, and other expendable items):

Autres dépenses (telles que location de matériel combustible explosifs et autres articles):

In support of this statement I attach receipts, invoices and other pertinent documents.

Joindre reçus, factures et autres pièces justificatives.

Signature