Citizenship and
Citoyenneté et
B
PROTECTED WHEN COMPLETED -
Immigration Canada
Immigration Canada
PAGE 1 OF 1
SOLEMN DECLARATION
CONCERNING A PERMANENT RESIDENT CARD THAT WAS LOST, STOLEN,
DESTROYED OR NEVER RECEIVED
ALL QUESTIONS MUST BE ANSWERED. IF SOME QUESTIONS DO NOT APPLY TO YOU, ANSWER "N/A" ("NOT APPLICABLE").
Surname (Family name)
Given name(s)
Client ID number
(YYYY-MM-DD)
City/Town
Country
1. Details
at
of birth
2. Permanent address:
No. and street
Apt. no.
City
Province
Postal code
Permanent Resident Card (PR Card) number (if applicable):
Home Telephone number (Area code and number)
Business Telephone no. (Area code and number)
Ext.
3. My Permanent Resident Card (PR Card) was:
Lost
Stolen
Destroyed
Never received
(YYYY-MM-DD)
City/Town
Country
On or
at
about
Under the following circumstances (full information must be provided below):
4. I have made the following efforts to locate this document (if applicable indicate police authorities notified and attach a copy of police report or incident report number):
5. Should I ever regain possession of the original document, I promise to return it immediately to a Citizenship and Immigration Centre or, if I am abroad, to the nearest
Canadian Embassy, Consulate or High Commission.
I solemnly declare that the information I have provided is true, that it is of the same force and effect as if made under oath, and that it was freely given. I authorize the
department of Citizenship and Immigration Canada to verify the information I have provided. I also understand that the provision of any false or misleading information
may lead to prosecution in accordance with Section 127 of the Immigration and Refugee Protection Act.
(YYYY-MM-DD)
Signature
►
►
Date
of declarant
Signature
(YYYY-MM-DD)
►
of parent or guardian
►
Date
if declarant is under
18 years of age
To report a PR Card that was lost, stolen, destroyed or never received, immediately submit this completed and signed form to Citizenship and Immigration
Canada by one of the following methods:
PR Card Processing Centre
Mail it to the
P.O. Box 9000
Sydney, Nova Scotia
B1P 6K7
or fax it to the PR Card Processing Centre at 1-902-564-3148
IMM 5451 (09-2003) E
(DISPONIBLE EN FRANÇAIS - IMM 5451 F)
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