Statutory Declaration of Common Law Union

Statutory Declaration of Common-law Union

(Single signature)

SECTION A - TO BE COMPLETED BY THE APPLICANT

Canada, Province or Territory of
Social Insurance Number

To Wit:

In the matter of the Canada Pension Plan and the Old Age Security Act and In the Matter of Common-Law Union

I, , of , in the province or territory of , solemnly declare that , and I lived together for continuous year(s) from to .

1. Are there children of the common-law union? This would include adopted children or children of one common-law partner to whom the other acted as a parent.

No Yes If yes, please provide the following information:

The following is information on each child. (If more space is required, attach a separate sheet.)

2. My common-law partner and I:

a) Jointly signed a residential lease, mortgage or purchase agreement relating to a residence in which we both lived. Yes No

b) Jointly owned property other than our residence. Yes No

c) Had joint bank, trust, credit union or charge card accounts. Yes No

3A. I had life insurance on myself that named my common-law partner as beneficiary. Yes No

3B. My common-law partner had life insurance on him/herself that named me as beneficiary. Yes No

4. If none of the above sections apply, what other documentary evidence are you aware of that would support your conjugal relationship as common-law partners?

I hereby declare that, to the best of my knowledge, the information on this declaration is true and complete. I realize that my personal information is governed by the Privacy Act and may be disclosed where authorized under the Old Age Security Act and the Canada Pension Plan. NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the Canada Pension Plan or the Old Age Security Act, or may be charged with an offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid.

Your Name (Please print)
Your Signature

Was the form completed and signed by someone other than the applicant?

If yes, that person must complete the section below and submit proof that they are authorized to act on behalf of the client. Call us at 1-800-277-9914 to find out what documents are required.

Name
Relationship to applicant
Telephone number
Date

Address
Signature

SECTION B - TO BE COMPLETED BY THE COMMISSIONER FOR OATHS

Declared before me at , county of , in the province or territory of this day of , .

Name of Commissioner and Organization (Please print)
Signature of Commissioner
Commissioner Authority Number (if applicable)

Service Canada delivers Human Resources and Skills Development Canada programs and services for the Government of Canada.

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Service Canada Offices - Canada Pension Plan

Mail your forms to: The nearest Service Canada office listed below. From outside of Canada: The Service Canada office in the province where you last resided.

Need help completing the forms? Canada or the United States: 1-800-277-9914; All other countries: 613-990-2244 (we accept collect calls); TTY: 1-800-255-4786.

Important: Please have your social insurance number ready when you call.

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