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To be used for recording costs in support of form PWGSC-TPSGC 1111.

Contractor's Name and Address:

Claim No.:

Date (YYYY-MM-DD):

File No.:

Contract Serial No.:

Financial Code(s):

Contractor's GST/HST No.:

Contractor’s QST No.:

Description: (Expenditures must be claimed in accordance with the basis and/or method of payment of the contract)	Current Claim		Previous Claims		Total to Date (A + B)
	(A) 3 decimal	Tax Rate a	(B) 3 decimal	Tax Rate b	Total to Date (A + B)
Description 1		%		%
Description 2		%		%
Description 3		%		%
Description 4		%		%
Description 5		%		%
Subtotal:
Applicable taxes:
Total:
Table note ^a Enter the applicable tax rate, for example 5 or 14 or 14.975 (do not use comma). Table note ^b Enter the applicable tax rate, for example 5 or 14 or 14.975 (do not use comma).