Imm 5492 E - Sponsor Assessment

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SPONSOR ASSESSMENT

Name of sponsoring group

Name of sponsor - Surname (Family name)

Given names

Other names used (include birth name, maiden, previous married names, aliases and nicknames)

Yes

Are you 18 years of age or older?

Yes

Are you a Canadian citizen, a Registered Indian or a permanent resident?

Yes

Do you or your representatives reside in the expected community of resettlement?

Have you been convicted inside Canada of the offence of murder or an offence set out in Schedule I or II of the

Yes

Corrections and Conditional Release Act? (see next page)

Have you been convicted outside Canada of an offence that, if committed in Canada, would constitute one of the

Yes

offences referred to above?

(If you have received a pardon or final determination of acquittal, or if five years have elapsed since the completion of the

sentence imposed, the conviction referred to above will not render you ineligible to sponsor refugees and you are not

required to disclose the conviction details.)

If Yes, provide conviction details below.

Conviction details:

Charge

Date (YYYY-MM-DD)

Place

Yes

Are you in default of any court-ordered support payment obligations?

Are you currently detained in any penitentiary, jail, reformatory or prison?

Yes

Have you been ordered to leave Canada?

Yes

Are you subject of revocation proceedings under the Citizenship Act?

Signature

I declare that the information given on this form and any attached documents are true, complete and accurate.

Sponsor signature

Date (YYYY-MM-DD)

The information you provided on this form is collected under the authority of the Immigration and Refugee Protection Act and will be used to maintain a record of application and

sponsorship undertakings of refugees according to the requirements of the Act. It will be retained in the Personal Information Bank CIC PPU 008 identified in Infosource. It may be

shared with other organizations in accordance with the consistent use of information under the Privacy Act. Under the Privacy Act and the Access to Information Act individuals have

the right to protection of and access to their personal information. Details on these matters are available at infosource.gc.ca and through the Citizenship and Immigration Call Centre.

Infosource is also available at Public Libraries in Canada.

IMM 5492 (05-2015) E

(DISPONIBLE EN FRANÇAIS - IMM 5492 F)