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A-0521-CA
(2012-11)

Declaration by spouse or de facto spouse

Reserved for Administration
Individual Reference No. :
File No. :

IMPORTANT
This declaration must be signed by the principal applicant and by his accompanying spouse or de facto spouse if the principal
applicants marital status is that of spouse or if he has a 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 SPOUSE
Declaration of the principal applicant
I __________________________________________________________________________________________ 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 person, 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 and country

____________________________________________________________________
Signature of the principal applicant

Declaration of the spouse accompanying the principal applicant

I __________________________________________________________________________________________ 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 person, I was married to another person.
I have a de facto spouse, and have been living separated and apart from my spouse since

.
Year

Month

Day

Year

Month

Day

In witness whereof, I have signed in ____________________________________________________ , on

City and country

____________________________________________________________________
Signature of the spouse accompanying the principal applicant

Ministre de lImmigration et des Communauts culturelles

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A-0521-CA (2012-11)

DECLARATION BY DE FACTO SPOUSE

Declaration of the principal applicant
I ____________________________________________________________________ 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

.
Year

Month

Day

I have a conjugal relationship with ________________________________________ since

First name and family name

.
Year

Month

Day

Year

Month

Day

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

In witness whereof, I have signed in ____________________________________________________ , on
City and country

____________________________________________________________________
Signature of the principal applicant

Declaration of de facto spouse accompanying the principal applicant

I ____________________________________________________________________ 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

.
Year

Month

Day

I have a conjugal relationship with ________________________________________ since

First name and family name

.
Year

Month

Day

Year

Month

Day

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

In witness whereof, I have signed in ____________________________________________________ , on
City and country

____________________________________________________________________
Signature of de facto spouse accompanying the principal applicant

Ministre de lImmigration et des Communauts culturelles

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A-0521-CA (2012-11)