Guide 5069 – Temporary Public Policy: Temporary Resident to Permanent Resident Pathway (TR to PR)

Statutory Declaration of Common-Law Union (IMM 5409)

Who must complete this form?

This form must be completed and signed by the sponsor and common-law partner, only if the latter is a co-signer on the application

Question 1

Write the following information in the space provided:

• Country of current residence
• Province/state/territory of current residence
• Name of the declarant
• Name of the declarant’s partner
• Name of city, town, village
• Name of county (if applicable)
• Name of province/state/territory
• Name of the country
• Number of continuous year(s) in a conjugal relationship
• Date of the relationship (from-to)

Question 1A

Check the box to indicate if you have jointly signed a residential lease, mortgage or purchase agreement relating to a residence in which you both live.

Question 1B

Check the box to indicate if you jointly own property other than your residence.

Question 1C

Check the box to indicate if you have a joint bank, trust credit union or charge card accounts.

Question 1D

Check the box to indicate if you have declared your common-law union under the Canadian Income Tax Act (T-1 “General individual income Tax Return”)

Question 2

Check the box to indicate if you have life insurance on yourself which names your common-law partner as a beneficiary.

Question 3

Check the box to indicate if your common-law partner has life insurance on themselves which names you as a beneficiary.

Question 4

If you answered “no” to questions 1 to 3, indicate other documentary evidence you have that would indicate your relationship as common-law partners

Question 5

SOLEMN DECLARATION
Write the following information in the space provided:

• Name of the declarant
• Name of the declarant’s partner
• Name of the city, town, village
• Name of the county
• Name of the province/state/territory
• Name of the country
• Date (day, month, year)
• Signature of the declarant
• Signature of the declarant’s partner
• Name of the person who administered the declaration
• Select the person’s title from the choices provided
• Signature of the person who administered the declaration