KIA Student Funding Continuation Application

Permanent Mailing Address

Your T4A for income tax will be sent to this address.
Address

PO Box Number and Street Address

Street Address Line 2

Town/CityTerritory/Province

Postal Code
Email Address
Phone Number
Contact Information While at School (if different than above)
Address

PO Box and Street Address

Street Address Line 2

Town/CityTerritory/Province

Postal Code
Email Address
Phone Number

All Nunavut/NWT residents must apply for co-funding from the GN/GNWT in addition to IPSE funding.

Deadlines:
- Fall Semester - SFA June 30
- FANS/ALTS - July 15
- Winter Semester - SFA October 31; FANS/ALTS November 15
- Spring/Summer Semester - SFA 30 days prior; FANS/ALTS March 1
Have you applied for FANS, SFA, ALTS or any provincial student aid?

YesNoIn Progress
Please upload your approval/denial letter from FANS/SFA/ALTS/provincial student aid

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Will you be receiving salary or financial assistance from any other agency or organization while attending school?

YesNo
If YES, from whom? (do not include scholarships)
Will you be receiving Employment Insurance?

YesNo
If YES, what year/month did your benefits start?
Will you be receiving any benefits from a First Nations Band?

YesNo

Dependents
I declare that the dependents listed below meet the following conditions: I have legal custody or guardianship of these dependent(s) who are under 18 years of age and are financially dependent upon me, and are living with me at least 50% of the time in each semester I am receiving assistance. See IPSEP policy for more information about dependents. ***Foster child(ren) are not eligible***

Dependent 1
Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to You
Will they be living with you while you are at school?

Dependent 2
Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to You
Will they be living with you while you are at school?

Dependent 3
Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to You
Will they be living with you while you are at school?

Dependent 4
Name

First NameLast Name
Date of Birth

MonthDayYear
Relationship to You
Will they be living with you while you are at school?

Requested Supports

PSE Coordinator can provide assistance if required.
Tuition and Fees
Please upload proof of tuition and fees per semester

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Estimated Costs
Required Textbooks and Supplies
Please upload a books and supplies list as required by the institution

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Estimated Costs
Relocation to School
Please include costs for round trip airfare for yourself and your dependents. If single with no dependents, you are eligible for a trip home at Christmas break.
How many people are travelling?
Estimated Costs
Distance from airport to institution (if ground travel is required)
Living Allowance Rates
Please Indicate
Child Care Subsidy
Maximum subsidy is $40/day per eligible child. Please note that spouses do not qualify for this subsidy.
Please indicate child care arrangement
Number of months that full-time childcare is required
Name of childcare provider:
Estimated Costs (max $40/day)
Rent/Residence Subsidy
Students may receive an allowance to assist with their portions of the costs for rent/mortgage if they meet the following requirements:
- For Rent: if the student is required to relocate to the community where the institution is based and their name is on the rental agreement.
- For Mortgage: the student's name must be included on the mortgage agreement.
- Residence: student's portion to be paid directly to the institution; indicate if meals are included or not included.

Declaration & Authorization to Release Information
I have read and understand the DECLARATION & AUTHORIZATION TO RELEASE INFORMATION and hereby consent:
1. I understand that meeting the eligibility requirements does not guarantee funding. The actual amount of money received will be based on IPSEP funds available when the application is reviewed.
2. I agree to repay the amount of any financial assistance to which I am not entitled such as, but not limited to: any payments made to me in error; and/or any payments made for costs in excess of the amount actually incurred; and/or any payments that were used for costs that were not eligible or reimbursement under the contribution agreement.
3. I declare that the information given above is true, correct, completed and understand that it may be subject to verification. I understand that it is an offence to make false statements.
4. I understand that the Kitikmeot Inuit Association will share the above information with the Government of Canada (GOC), and that I consent to the disclosure of this information to GOC.
5. I have been advised by Kitikmeot Inuit Association that the information that I provided is protected under Canada’s Privacy Act and that I have a right under the Privacy Act to obtain access to that information from GOC.
6. I hereby authorize Service Canada to release information about the status and benefit rate of my Employment Insurance claim to Kitikmeot Inuit Association to determine my eligibility for the program and/or for alternative income support.
7. I hereby authorize Kitikmeot Inuit Association to release and/or request information as required from Nunavut Government Department of Family Services, Department of Education, Financial Assistance for Nunavut Students (FANS), NWT Student Financial Assistance (SFA), my childcare provider, and my landlord to determine my eligibility for the program and for verification purposes throughout the duration of the program.
8. I authorize Kitikmeot Inuit Association at any time to request for information regarding my academic progress including enrollment confirmation, education costs, and transcripts from the educational institution that I will be attending.
9. I agree to the use of my name, pictures, data and other relevant information by Kitikmeot InuitAssociation in documentary, newsletters, and statistics relevant to the training programs, andKitikmeot Inuit Association having exclusive rights to use the picture, video, statistics and relevant information at any time and for future use by the Kitikmeot Inuit Association. I will have no future claim to the information, data, or pictures. In other words, KIA may use photos and other information gained during the program in KIA related business and reports.
10. This authorization will remain in effect UNLESS I give written instruction to cancel the authorization.
Applicant Name

First NameLast Name
Signature

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Application Date

MonthDayYear
Date
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KIA Student Funding Continuation Application

Permanent Mailing Address

Contact Information While at School (if different than above)

All Nunavut/NWT residents must apply for co-funding from the GN/GNWT in addition to IPSE funding.

Dependents

Program Information

Requested Supports

Tuition and Fees

Required Textbooks and Supplies

Relocation to School

Living Allowance Rates

Child Care Subsidy

Rent/Residence Subsidy

Declaration & Authorization to Release Information