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PAGE 3 OF 3

FOR CIC USE ONLY

Financial Commitment

Financial Requirement

Funds held in trust

Total Cost of Sponsorship: (column C below)

Member 1 Financial Commitment

+ $

Member 2 Financial Commitment

Member 3 Financial Commitment

+ $

- $

Total In-Kind Deduction: (from page 1)

+ $

Member 4 Financial Commitment

+ $

Member 5 Financial Commitment

Total Financial Commitment :

= $

Final Cost of Sponsorship :

= $

Sponsorship Cost Table ($)

12 Months of Income

Estimated Total Annual

Family Size

Start-up Costs

Support

Settlement Cost ($)

9,800

2,800

12,600

16,800

4,400

21,200

17,700

5,300

23,000

20,000

7,000

27,000

22,500

7,200

29,700

24,500

8,000

32,500

Additional member

1,550

1,000

2,500

In-Kind Deduction Table ($)

School

Family Size

Shelter

Clothing

Furniture

Start-up Costs

Food Staples

Start-up Costs

6,000

500

1,500

325

175

7,100

1,000

2,000

350

250

7,800

1,375

2,500

375

325

8,400

1,750

3,000

400

9,600

2,125

3,500

425

475

9,600

2,500

4,000

450

550

For each additional member, add

900

375

500

150 per child

between ages

4 - 21

F - DECLARATION

I declare that the information given on this form and any attached documents are true, complete and accurate.

SIGNATURE OF

GROUP REPRESENTATIVE

Signature

Date (YYYY-MM-DD)

The information you provided on this form is collected under the authority of the Immigration and Refugee Protection Act and will be used to maintain a record of application and

sponsorship undertakings by local Groups of Five or more individuals according to the requirements of the Act. It will be retained in the Personal Information Bank CIC PPU 008

identified in Infosource. It may be shared with other organizations in accordance with the consistent use of information under the Privacy Act. Under the Privacy Act and the Access

to Information Act individuals have the right to protection of and access to their personal information. Details on these matters are available at infosource.gc.ca and through the

Citizenship and Immigration Call Centre. Infosource is also available at Public Libraries in Canada.

IMM 5373A (08-2015) E