Business Assistance–Immigrant Investor Program (IMIN)
APPLICATION FOR DISBURSEMENT OF NON-REFUNDABLE CONTRIBUTION No. ____
Please complete and return this form to:
IQ Immigrants Investisseurs inc. Attention of (Responsible for the file and address of IQ Immigrants Investisseurs inc. concerned)
IDENTIFICATION OF COMPANY
Name
Business name (if different from legal name)
Address
Attention	IQ File no.
Professional telephone	Professional email
GENERAL INFORMATION
Title of project:
Yes	No
Has control of the company changed since the agreement was signed with IQ Immigrants Investisseurs inc.?
Have the assets related to the project been sold since the agreement was signed with IQ Immigrants Investisseurs inc.?
Have there been major changes in the nature of the project and the amounts realized compared with the amounts forecast in the agreement? (If so, please attach details.)
As regards financing of the project, has the company received further offers of government or non-government funding or have changes been made to any such offers declared in the agreement? (if so, please attach details)
Is the company or any other associated company in default under the terms of an act or agreement with Investissement Québec or one of its subsidiaries or any other financial institution?
DOCUMENTATION TO ENCLOSE WITH THIS APPLICATION To be complete, this application must: Be signed by the duly authorized representative of the company; Contain all the following documents (if not already supplied): - the most recent periodic financial statements; - the company's most recent annual financial statements; certification by an independant auditor regarding expenses incurred in connection with the project and the financing, in accordance with the terms of payment in the agreement; a progress report on the project. - Information and supporting documents related to any clauses specific to the project must also be supplied, where applicable.
DECLARATION BY THE COMPANY
I, the undersigned,
duly authorized representative of the company, hereby certify that the information provided in this application for disbursement and the attached documents is, to the best of my knowledge, complete and accurate in all respects. If applicable, I the undersigned duly authorized representative of the company, hereby represent and guarantee on behalf of the company to Investissement Québec that the company has obtained, in accordance with the law, all consents required from all individuals concerned by the personal information disclosed in this form or in relation therewith.
Title of signatory	Signature	Date
3.9.4.222IIA (23-10)