Statuory Declaration/yukon Business Incentive Policy For Construction/rebate Claim Form
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1STATUTORY DECLARATION
YUKON BUSINESS INCENTIVE POLICY FOR CONSTRUCTION
YUKON LABOUR, APPRENTICE, YOUTH, AND/OR MATERIALS INCENTIVE
REBATE CLAIM
IN THE MATTER OF a contract bearing No. _____________________________________________
between the Government of the Yukon and _____________________________________________
(Full name of Contractor)
for _____________________________________________________________________________
(Description and location of the Work)
dated the _________ day of ________________________ 20 __________
AND IN THE MATTER OF a Business Incentives Rebates Claim covering Yukon labour, apprentices,
youth and/or Yukon Materials; in work done and/or Yukon manufactured materials incorporated into
work done thereunder:
from the _________ day of ________________________ 20 __________
to the ____________ day of ________________________ 20 __________
by the Contractor/Subcontractor
________________________________________________________________________________
(Full name of Contractor/Subcontractor)
TO WIT:
I, _______________________________________ OF _____________________________________
(Declarant’s Address)
(Full name of Declarant)
do solemnly declare:
1.
That I am ____________________________________________________________________
(Declarant’s title/position with the Contractor or state that the Declarant is the Contractor/Sub-Contractor)
and as such have a personal knowledge of the Contract and of the facts and matters, includ-
ing the Business Incentive Claim for Yukon labour, apprentices, youth and/or material declared
herein, said personal knowledge resulting from, among other things, an examination of the
books and records of the Contractor/Subcontractor.
2.
That, all labour, including apprentice and youth labour, listed in this claim is valid as stated.
3.
That, where materials are listed in this claim, they were manufactured in the Yukon, and are
listed in the applicable Rebate Schedule.
4.
That, where materials are listed in this claim, they were on site and were used in this work, and
that any materials not used have been deducted.
5.
That, this Business Incentive Rebates Claim is valid and correct.
And I make this SOLEMN DECLARATION conscientiously believing it to be true, and knowing that it
is of the same force and effect as if made under oath and by virtue of the CANADA EVIDENCE ACT.
Declared before me at this __________day of _____________________20 ________
__________________________________
__________________________________
(Signature of Declarant)
(Signature of person before whom declaration is made)
__________________________________
(Print name of person before whom declaration is made)
A Notary Public, in & for the Yukon Territory.
(Please clearly state authority for receiving solemn declaration)
NOTICE
If this Declaration is not complete in every detail, it may be returned for completion and payment will
be delayed.
YG(4984Q)F1 Rev.05/2014
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