Statutory Declaration of Common-Law Union
New Brunswick Provincial Nominee Program (NBPNP)
APPLICANT DETAILS
Family name(s) exactly as shown on your passport or travel document Date of birth (mm-dd-yyyy)
First name(s) exactly as shown on your passport or travel document Middle name(s) exactly as shown on your passport or travel document
In the matter of establishing eligibility as a common-law partner pursuant to the Immigration and Refugee Protection Act and Regulations and in the matter
of common-law union, we, ______________________________________________ and ________________________________________________
(name of declarant) (name of declarant’s partner)
of ______________________________________ county of ________________________________ in _____________________________________
(name of city, town, village) (if applicable) (name of provide, state, territory)
in the country of _________________________________________________, solemnly declare that we have cohabited in a conjugal relationship for
(name of country)
________________ continuous year(s) from __________________________________ to ________________________________
(number of years) date (mm-dd-yyyy) date (mm-dd-yyyy)
My common-law partner and I: If none of the categories apply, what other documentary evidence do you have
that would indicate your relationship as common-law-partners?
have jointly signed a residential lease, mortgage or purchase
agreement relating to the residence in which we both live+
jointly own property other than our residence+
have joint bank, trust, credit union or charge card accounts+
one of us has life insurance which names my common-law
partner as beneficiary+
+ Copies of relevant documents must be attached
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SOLEMN DECLARATION
We do solemnly declare that the information we have given in the forgoing application is truthful, complete and correct, and we make this solemn declaration
believing it to be true and knowing that it is of the same force and effect as if made under oath. We understand that any false statements or concealment of
a material fact may result in our exclusion from the NBPNP. We understand all the above information, having had the opportunity to ask for or having asked
for and obtained an explanation on every point which was not clear to us.
_____________________________________________________ ____________________________________________________
Signature of declarant Date (mm-dd-yyyy)
_____________________________________________________ ____________________________________________________
Signature of declarant’s partner Date (mm-dd-yyyy)
Solemnly declared before me at _____________________________ county of ________________________ in _____________________________
(name of city, town, village) (if applicable) (name of province, state, territory)
in the country of _______________________________ this ________ day of ______________, 20_____.
(name of country)
Professional chop/stamp
____________________________________________________________________
Signature of notary public, commissioner of oaths or commissioner of taking affidavits
Personal information on this form is collected under the authority of the Immigration and Refugee Protection Act, SC 2001 c.27. The purpose of the
collection is to process your application for the New Brunswick Provincial Nominee Program (NBPNP). The information will be used for research,
performance measurement and/or evaluation of the Program. If you have any questions about the collection and handling of personal information you
may contact the Director of Operations, Compliance and Integrity, Government of New Brunswick at Place 2000, 250 King Street, Fredericton New
Brunswick, Canada, E3B 9M9. Telephone: (506) 453-3981; Email: immigration@gnb.ca; Website: www.welcomenb.ca.
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