Fillable Form D34f - Statutory Declaration Spouse printable pdf download

200 – 1881 Scarth Street, Regina SK S4P 4L1

Phone: 306.787.4370

Toll free: 1.800.667.7590

D34F

Website:

Statutory Declaration – Spouse

_________________

Claim#

Province of Saskatchewan

Worker’s Name: _________________

To Wit:

do solemnly declare:

(Fill in name in full)

1. That I am the spouse of

who died on the

day of _________________

as the result of personal injury sustained while in the employ of

(Give city, town, or other place)

2. That I was born on the

day of

, _____.

My S.I.N.# is ______________________

3. That I was married to my above-named spouse on the

_ day of

__, ___ ___,

(Give city, town, or other places)

4. That at the date of my above-named spouse's death we were living together as husband and wife and

had been so living continuously since our said marriage except

___________________________________________________________________

(If any exception, give particulars and explanation; if no exception, so state)

5. That the names, dates of birth, and present residence of the children of the above-named spouse,

under the age of 25, now living, wholly or partly dependent upon the worker's earnings at the time of

death, are as follows:

Name

Date of Birth

Present Address

______________________

___/___/___

_______________________________

(dd/mm/yyyy)

______________________

___/___/___

_______________________________

(dd/mm/yyyy)

______________________

___/___/___

_______________________________

(dd/mm/yyyy)

6. That I am now residing at _______________________________________________________

(Give street name and number, if any)

in _______________________, in the Province of _____________________________

(Give city, town or other place)

That I claim compensation on behalf of myself and the above-mentioned children.

And I make this solemn declaration conscientiously believing it to be true and knowing that it is of the

same force and effect as if made under oath and by virtue of "The Canada Evidence Act".

Declared before me at the ________________of ____________in the ______________ of ___________.

this ________________________ day of ___________________________ A. D. 20______.

____________________________________

A Commissioner, J. P., or Notary Public

(Spouse sign here)

Updated: 01/16

Form D34f - Statutory Declaration Spouse

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