Form IV - Affidavit of Disbursements


Please note, affidavit text samples are provided throughout the sections of this form.
Text within [] brackets will be replaced by your answers when you print this form.

Additionally, you must fill the required fields below in order to print the affidavit of disbursements.

In accordance with the Commission's Guidelines for the Assessment of Costs, as set out in Telecom Regulatory Policy CRTC 2010-963, an affidavit, substantially in the form set out below, should be sworn or affirmed by an officer of the applicant or by its legal counsel (the affiant)

Header and Introduction of Affiant

In the matter of the assessment of costs of [Applicant Name] related to [Proceeding No].

I, [Name of the affiant] of the [City/Town of the affiant] in the [County/Regional Municipality of the affiant] in the [Province of/Territory of the affiant], [Make oath and say or Affirm]:

Make oath and say or Affirm: (required)

Paragraph 1

1. I am [Full name of affiant] of the applicant [Name of Applicant], and as such have knowledge of the matters to which I hereinafter depose.

Paragraph 2

2. Attached to my affidavit as Exhibit A is/are [Number of sheets] sheet(s) setting out the disbursement claims in the amount of [insert total dollar amount of disbursements] for [Brief description of disbursement claims by category] and the required evidence of disbursement (receipts and other supporting documentation as required under section 41 of the Commission's Guidelines for the Assessment of Costs, revised as of 23 December 2010), and which has/have been prepared in accordance with those Guidelines.


Paragraph 3

3. To the best of my knowledge and belief, the disbursement claims of [Name of Applicant] submitted herewith, and all the documentation in support, represent disbursements incurred necessarily and reasonably for the purpose of the proceeding.

Paragraph 4

4. If applicable, the disbursement claims submitted herewith are made in accordance with the Commission's determination set out in Telecom Order CRTC [Order number] and do not exceed the costs permitted therein.

Paragraph 5

5. If applicable, the applicant has submitted claims for meals in accordance with sections 34 and 35 of the Guidelines. To the best of my knowledge and belief, these claims represent disbursements incurred for the purpose of this proceeding and do not lead to double recovery.

Is this paragraph applicable? (required)

Paragraph 6

6. The applicant has received/will receive/has not received financial assistance in connection with its participation in the proceeding. [If applicable, describe financial assistance, including total dollar amount].

Financial assistance (required)

Paragraph 7

The applicant is not entitled to a rebate in connection with any applicable tax/The applicant is entitled to the following rebate in connection with the following taxes [If applicable, the rebate is on the basis of (basis of eligibility for rebate):

  • GST:
  • Federal Part of HST
  • PST:
  • Provincial Part of HST
  • Other Tax and rebate percentage, if applicable:]

Is the applicant entitled to a rebate? (required)
Please specify which rebates: (required)
Please specify the rebates percentage:

[SWORN OR AFFIRMED] BEFORE ME of the [City/Town] in the [County/Regional Municipality of the Affiant] in the [Province of or Territory of] on [Date]

SWORN Or AFFIRMED: (required)
Date modified: