Declaration by spouse or de facto spouse

Reserved for Administration

Individual Reference No. :

Note : In order to lighten the text, the terms and expressions

used encompass both grammatical genders

File No. :

IMPORTANT
This declaration must be signed by the principal applicant and by his accompanying spouse if the principal applicants marital
status is that of spouse.
Both individuals must sign this form. Otherwise, it will be returned.

IDENTIFICATION OF THE PRINCIPAL APPLICANT

Family name at birth

First name

Date of birth

DECLARATION BY SPOUSE
Declaration of the principal applicant
I, the undersigned __________________________________________________________________ , declare that I am the spouse
First name and family name

of _________________________________________________________.
First name and family name

Please indicate if the statements below correspond to your situation.

Yes No
At the time of my marriage to this spouse, I was married to another person.
I have a de facto spouse, and have been living separated and apart from my spouse since ______ / ______ / ______.
In witness whereof, I have signed in ______________________________________________________ , on ______ / ______ / ______.
City / Country

____________________________________________________________________
Signature of the principal applicant

Declaration of the spouse accompanying the principal applicant

I, the undersigned __________________________________________________________________ , declare that I am the spouse
First name and family name

of _________________________________________________________.
First name and family name

Please indicate if the statements below correspond to your situation.

Yes No
At the time of my marriage to this spouse, I was married to another person.
I have a de facto spouse, and have been living separated and apart from my spouse since ______ / ______ / ______.
In witness whereof, I have signed in ______________________________________________________ , on ______ / ______ / ______.
City / Country

____________________________________________________________________
Signature of the spouse accompanying the principal applicant

Ministre de lImmigration et des Communauts culturelles

A-0521-CA (2009-02)

IMPORTANT
This declaration must be signed by the principal applicant and by his accompanying de facto spouse if the principal applicants
marital status is that of de facto spouse.
Both individuals must sign this form. Otherwise, it will be returned.

IDENTIFICATION OF THE PRINCIPAL APPLICANT

Family name at birth

First name

Date of birth

DECLARATION BY DE FACTO SPOUSE

Declaration of the principal applicant
I, the undersigned ____________________________________________________________________ declare that
First name and family name

Please indicate if the statements below correspond to your situation.

Yes No
I live conjugally with and cohabit with __________________________________________________________________
First name and family name

since ______ / ______ / ______.

I live conjugally with ______________________________________________________ since ______ / ______ / ______ ,
First name and family name

but, being subject to persecution or penal control, we cannot live together.

In witness whereof, I have signed in ______________________________________________________ on ______ / ______ / ______.

City / Country

____________________________________________________________________
Signature of the principal applicant

Declaration of de facto spouse accompanying the principal applicant

I, the undersigned ____________________________________________________________________ declare that
First name and family name

Please indicate if the statements below correspond to your situation.

Yes No
I live conjugally with and cohabit with __________________________________________________________________
First name and family name

since ______ / ______ / ______.

I live conjugally with ______________________________________________________ since ______ / ______ / ______ ,
First name and family name

but, being subject to persecution or penal control, we cannot live together.

In witness whereof, I have signed in ______________________________________________________ on ______ / ______ / ______.

City / Country

____________________________________________________________________
Signature of de facto spouse accompanying the principal applicant