Service PROTECTED B (when completed)
Canada Personal Information Bank
Statutory Declaration of Common-law Union ESDC PPU 116 and 146
(Dual signatures)
Social Insurance Number
SECTION A - TO BE COMPLETED BY THE APPLICANT
In the Matter of the Canada Pension Plan and the
Canada Old Age Security Act and
To Wit:
PROVINCE / TERRITORY OF In the Matter of Common-Law Union
I,
of the (City, Town, Village) of county of in the province / territory of
Solemnly Declare, that name of common-law partner
and I have been .
continuous year(s) from to
living together for number of years YYYY-MM-DD YYYY-MM-DD
1. Are there children of the common-law union? This would include adopted children or If yes, please provide the
No Yes
children of one common-law partner to whom the other acts or has acted as a parent. following information:
The following is information on each child. (If more space is required, attach a separate sheet.)
First Name Legal Family Name Family Name commonly used Date of Birth
2. My a) Jointly signed a residential lease, mortgage b) Jointly owned property other than c) Have/had joint bank, trust, credit union or
common-law or purchase agreement relating to a our residence. charge card accounts.
partner and I: residence in which we both live(d).
Yes No Yes No Yes No
3A. I have life insurance on myself that names my common-law partner as 3B. My common-law partner has life insurance on him/herself that
beneficiary. names me as beneficiary.
Yes No Yes No
4. If none of the above sections apply, what other documentary evidence are you aware of that would support your conjugal relationship as
common-law partners?
I hereby declare that, to the best of my knowledge, the information on this declaration is true and complete. I realize that my personal
information is governed by the Privacy Act and may be disclosed where authorized under the Old Age Security Act and the Canada
Pension Plan.
NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty and interest, if any, under the
Canada Pension Plan or the Old Age Security Act, or may be charged with an offence. Any benefits you received or obtained to which there was no
entitlement would have to be repaid.
Your Name (Please print) Your Signature
Name of Common-law Partner (Please print) Signature of Common-law Partner
Was the form completed and signed by someone other than the applicant?
If yes, that person must complete the section below and submit proof that they are authorized to act on behalf of the client. Call us at 1-800-277-9914
to find out what documents are required.
Name Relationship to applicant Telephone number Date
Address Signature
X
SECTION B - TO BE COMPLETED BY THE COMMISSIONER FOR OATHS
Declared before me at , county of ,
name of city, town or village county
in the province or territory of this day of , .
province or territory day month year
Name of Commissioner and Organization (Please print) Signature of Commissioner Commissioner Authority Number
(if applicable)
Service Canada delivers Employment and Social Development Canada
programs and services for the Government of Canada
SC ISP-3004 (2014-08-01) E Disponible en français
Service
Canada
Service Canada Offices
Canada Pension Plan
Mail your forms to:
The nearest Service Canada office listed below.
From outside of Canada: The Service Canada office in the province where you last resided.
Need help completing the forms?
Canada or the United States: 1-800-277-9914
All other countries: 613-957-1954 (we accept collect calls)
TTY: 1-800-255-4786
Important: Please have your social insurance number ready when you call.
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SC ISP-3501-CPP (2018-01-18) E
