Fonds D Initiatives Du Plan Nord

FONDS D’INITIATIVES DU PLAN NORD

Application for financial assistance

*Information required for the processing of your application

Information about the applicant*

Name of the organization's official representative: / Title:
Applicant organization:
Postal address:
City: / QC / Postal code:
E-mail:
Phone: / Cell phone:
Fax:
Québec enterprise number (NEQ):
Tax reimbursement percentage to which your organization is entitled at Revenu Québec:
Tax reimbursement percentage to which your organization is entitled at Canada Revenue Agency:

contact informationfor the project coordinator*

Name of project coordinator:
Phone: Extension:
Fax:
E-mail:

Overview of the organization *

Legal status: Select one.
Applicant's main activities:
Date on which the organization started to operate:
Does the applicant formally apply a sustainable development process (defined sustainable development policy, strategy and/or action plan, BNQ 21000 diagnosis, etc.):
Yes: ☐ No: ☐
Specify:
Description of the organization (description, mission, historical background, expertise, covered territory, etc.):

Information on the project *

Title of project:
Goal of project:
Location of project:
Start date:Click to enter date / End date:Click to enter date
Amount requested from the Fonds d’initiatives du Plan Nord:
Total cost of project:

Description of project

Please describe the project for which financial assistance is requested as precisely as possible.
Based on:
The nature of the project
The objectives
The problem
The issues and needs
The partners involved
The expected benefits
The equipment used and the technology proposed
The project team
The innovative aspects
The market potential ora quantification of the client groups that will benefit from the project
The marketing/communications strategy
The contribution to environmental protection
For promoters submitting a study as a project: the promoter must show that the results of the study or project will be developed/will be implemented
You may add extra pages if you need more space.
Number of jobs created by the project * / Type of job / Number of jobs
Full-time
Seasonal
Part-time
Number of jobs maintained by the project * / Type of job / Number of jobs
Full-time
Seasonal
Part-time

Justification for financial assistance*

Show how the project is relevant to the problem and priority needs in the community, show how assistance from the Fonds d’initiatives du Plan Nord is necessary to complete the project, and show that the project has been submitted under other current assistance programs, and to any other para-governmental funding agency and/or private funding providers.
Based on:
Describe the steps taken to obtain financing for the project under other government programs, or from para-governmental programs or private funding providers.
Name the financial partners approached and the discussions under way at the time your application is submitted. Include all supporting documents showing the approaches made to these funding providers.
Show how financial assistance is necessary for the project.
Demonstrate the reasons why your organization does not have the financial capacity to carry out the project without the financial assistance of the Société du Plan Nord.
Show how the project is consistent with the policy directions and priorities of the Plan Nord.
Show how the project will remain viable after financial assistance has been received from the Société du Plan Nord and other partners.
Show the potential for attracting other investment.
You may add extra pages if you need more space

project stages and timeline *

project stage / start date / end date
1. / Click to enter date / Click to enter date /
2. / Click to enter date / Click to enter date /
3. / Click to enter date / Click to enter date /
4. / Click to enter date / Click to enter date /
5. / Click to enter date / Click to enter date /
6. / Click to enter date / Click to enter date /
7. / Click to enter date / Click to enter date /

Project costs and financing *

Planned expenditure
Detailed breakdown of expenditure and costs / Amount
$
$
$
$
$
$
$
Total / $

Sources of project financing *

Name the government departments, government bodies, enterprises and other financial partners. Indicate if the financial assistanceis confirmed and, where applicable, include the confirmation letter. / Type of financing / Amount / Confirmation
Société du Plan Nord / Grant - non refundable contribution / $ / ☐ /
Select one. / $ / ☐ /
Select one. / $ / ☐ /
Select one. / $ / ☐ /
Select one. / $ / ☐ /
Select one. / $ / ☐ /
Select one. / $ / ☐ /
Select one. / $ / ☐ /
Select one. / $ / ☐ /
Indicate all sources of private and public financing. Note that the applicant or community must provide a minimum 10% cash contribution for public projects.
The minimum cash contribution is 50% for private projects. / Total / $

* Only eligible expenditure is counted

**Expenditure and financing sources for the project must match.

Declarationand consent *

As the applicant's authorized representative, I declare that the information provided in this form is accurate and complete.
I understand that all the documents and information held by or on behalf of the Société du Plan Nord (hereinafter the "Société") are subject to the Act respecting access to documents held by public bodies and the protection of personal information, CQLR c. A-2.1, including any industrial, financial, commercial, scientific and technical information provided by the applicant in this form.
To verify the accuracy of the information provided in this form and determine the project's eligibility for financing from the Fonds d’initiatives du Plan Nord, I hereby authorize the Société to contact the organizations and enterprises directly or indirectly involved in the project, including organizations and enterprises likely to hold information on the financial assistance programs and sources of financing identified in sections D and E of this form, and to disclose to them the relevant information provided concerning the project and its financial framework, and I authorize those organizations and enterprises to disclose to the Société the information they hold on the financing of the project (amounts requested, status of applications, agreed terms and general financing conditions) and concerning the viability of the project, its usefulness and its impacts, if applicable.
A list of the organizations and enterprises likely to the consulted by the Société for the purpose of analyzing this application for financial assistanceis included in the appendix.If it is relevant to consult other organizations or enterprises, the Société will give the applicant prior notification.
Despite the above, the following information I have provided concerning the applicant or the project is strictly confidential and cannot be disclosed to any party except with the applicant's express consent or if disclosure is required by law:
I understand that if the information identified is relevant for the purpose of determining the project's eligibility for financing from the Fonds d’initiatives du Plan Nord, the Société may be unable to process this application for financial assistance. The same applies if I refuse to consent, wholly or partly, to the collection, use or disclosure of documents or information concerning the applicant or the project.
This authorization is valid from the date of signing until the date on which a decision is made concerning the application for financial assistance.
Signature or electronic signature:
Name (block letters): / Date: Click to enter date
Function:

Contact information

Send the completed form and appended documents, if any, to the following address:
E-mail: / Mail:
Fonds d’initiatives du Plan Nord
Société du Plan Nord
900, boulevard René-Lévesque, bureau 720
Québec (Québec) G1R 2B5
Fax: 418643-3660

Note:The Société may request other information.

documents that must be submitted with the application for financial assistance

☐Application form for financial assistance, completed, signed and dated
☐Copy of the promoter's last financial statement
☐Letters of support from project partners (if applicable)
☐Any other document considered relevant for the purpose of assessing the project

APPENDIX: list of organizations and enterprises likely to be consulted by the Société in order to analyze the application for financial assistance (to be determined on the basis of the type of project and the partners associated with the project)

Provincial government departments

Federal government departments

Government bodies

Regional county municipalities (MRC)

Municipalities

Municipal and paramunicipal corporations

Aboriginal administrative and political organizations

Educational institutions

Unions

Financial institutions

Personal information agents

Without limiting the general scope of the above:

Local development centres (CLD)

Société d’aide au développement des collectivités (SADC)

Investissement Québec

Caisse de dépôt et placement du Québec (CDPQ)

Business Development Bank of Canada (BDC)

Confédération des syndicats nationaux (CSN)

Fonds de solidarité de la Fédération des travailleurs et travailleuses du Québec (FTQ)

Desjardins capital de risque

Financière agricole du Québec

Farm Credit Canada

National Research Council Canada (NRC)

Band councils

Corporation de développement économique montagnaise (CDEM)

Colleges

Universities

Regional tourism associations