Free PPTC 203 - Statutory declaration - Canada

STATUTORY DECLARATION
concerning a lost, stolen, damaged, destroyed or
inaccessible Canadian passport or travel document

Print in block letters using black or dark blue ink

INFORMATION PROTECTED

Applicant's Personal Information
Surname Date of Birth
Year Month Day City Province/Territor y (if applicable) Country

Given Name(s) Place of Birth

Declaration of Applicant
1. I hereby declare that
Type of Document

, number
Document Number

, issued at became
Place of issue

in my name or lost damaged

my child's stolen destroyed

name,
Child's Name

, on
Year Month Day

or

inaccessible on
Year Month Day

at
City (Exact location)

under the following circumstances (full and detailed information must be provided below):

2. I have made the following efforts to locate this document:

Police Report Filed

No

Yes (Specify)

Date of Report
Year Month Day

No.

3. This document was last seen or used

4. Should I ever regain possession of the above original document, I promise to return it immediately to Passport Canada, or, if I am abroad, to the nearest Canadian government office. I acknowledge that a Canadian passport, once reported lost or stolen, is no longer valid and is not to be used for any travel. DECLARATION - I solemnly declare that, to my knowledge, the statements made in this declaration are true. Date
Year Month Day

Signed at
City Province/Territor y

Signature

This form must be completed before, and signed by, a qualified official who has the authority to administer an oath or solemn declaration (e.g. a commissioner for oaths, notary public, lawyer, etc.). If completed outside Canada, a qualified official includes a Canadian or British diplomatic or consular representative, or a qualified local official.

Declaration of Official
Surname Given Name(s)

As Address
Number

Commissioner for Oaths

Lawyer

Notary Public

Other qualified official (Specify)

Street

Appartment

City

Province/Territor y

Postal Code

Home Telephone Number

Business Telephone Number/Extension

Fax Number or E-Mail Address (Optional)
Français au verso PPTC 203 (09-04)

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)
Date Year
Month Day

DECLARATION made before me on
Signed at
City

Province/Territor y

Signature of Official