NWT Student Financial Assistance
FORM A - TRAVEL CLAIM
Please use this form to receive a reimbursement for your eligible expenses for air, land or water transportation after you have travelled.
You must request a reimbursement during the same academic year that you received SFA funding. (Complete one form for each trip you
make travelling by air, land or water.) Please keep your receipts for travel as you may be required to provide them now, or at a later
date.
STUDENT INFORMATION
First and Last Name
Date of Birth - YY/MM/DD
Home Community in the Northwest Territories
TRAVEL INFORMATION
Travelled From (Community):
Territory/Province
Travelled To (Community):
Territory/Province
Mode of Travel:
Air (attach receipt and itinerary)
Land
Water
Date of Travel - YY/MM/DD:
DECLARATION
I certify that I have incurred these expenses for the purpose of attending postsecondary studies and I am
now seeking reimbursement.
X
Signature
[email protected]
Date - YY/MM/DD
SFA PID
www.nwtsfa.gov.nt.ca
This information is being collected under the authority of the Access to Information and Protection of Privacy (ATIPP) Act, Section 41.(1)(g) and the Northwest Territories Student Financial
Assistance (SFA) Act and Regulations. The information will be used to determine my initial and continued eligibility for SFA and for the general administration and enforcement of this program.
The privacy provisions of the ATIPP Act protect my information, and all applicants have the right to examine and request correction of his or her records and to request a review by the Information
and Privacy Commissioner. If you have any questions about the collection of information, contact the SFA Manager, Department of Education, Culture and Employment, Box 1320, Yellowknife,
NT X1A 2L9, or call 1-800-661-0793 or 1-867-767-9355.
NWT8713/0617
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