Free CIT 0012E - Canada

Fillable Form
Citizenship and Immigration Canada Citoyenneté et Immigration Canada
PAGE 1 OF 5 PROTECTED WHEN COMPLETED - B

ADOPTEE'S APPLICATION

PART 2

APPLICATION FOR CANADIAN CITIZENSHIP FOR A PERSON ADOPTED BY A CANADIAN CITIZEN (ON OR AFTER JANUARY 1, 1947)

FOR OFFICIAL USE ONLY
Send certificate to: Return original document(s) Canadian address Citizenship granted Mission outside of Canada Receipt no. Citizenship refused Client ID CPC-S

Certificate no. Signature OFFICE PROCESSING - PART 2 Name of officer (PRINTED)
Year Month Day

SPACE RESERVED FOR APPLICANT'S PHOTO (do not staple)

File no.

Mission Date Place (city/town)

Before you start completing this form, make enough photocopies for your needs. You can also print all or part of this form from our Web site at www.cic.gc.ca. If there is not enough space to provide all the necessary information, attach to this form a separate sheet of paper with further details. Print your name at the top of each additional sheet and indicate the form's title and the number of the question you are answering.

BEFORE YOU START, READ THE APPLICATION GUIDE
TYPE or PRINT in black or blue ink
1A Last name (surname/family name) as indicated on the adoption order 1B
I want service in English French Check Given name(s) as indicated on the adoption order

( ) one

2
I have special needs No Yes If yes, explain
Year Month Day

3

You must receive confirmation that Part 1 (CIT 0010) was approved before submitting Part 2 (CIT 0012) of the application. What is the date on the decision letter that confirmed that at least one of the parents was a Canadian citizen?

4
A

APPLICANT'S INFORMATION
Who is applying on behalf of the adopted person for Canadian citizenship? The adoptive parent The adopted person (if aged 18 years or older) The legal guardian

Note: Adopted persons 18 years of age or older must fill in and sign their own application.
B

Name and addresses of the person applying for the adopted person's Canadian citizenship Given name(s) Last name (surname/family name)

C

Residential address No. & street

D

Apt./unit

Mailing address (if different from Section 4C) No. & street

Apt./unit

City/Town

Province/Territory

City/Town

Province/Territory

Postal code

Country

Postal code

Country

E

Country code

Area code

No.

Country code

Area code

No.

Home telephone no.
Country code Area code No.

Cellular phone no.
Country code Area code No.

Business telephone no.

Facsimile no.

E-mail address This form is made available by Citizenship and Immigration Canada and is not to be sold to applicants. (DISPONIBLE EN FRANÇAIS - CIT 0012 F)

CIT 0012 (04-2009) E

5
A

ADOPTION DETAILS
Year Month Day

PAGE 2 OF 5

When was the adoption completed? Place (city/town) Region/Province Country

B

Where was it completed?

C

Age of adopted person at time of adoption Is the adopted person a relative of one of the adoptive parent(s)? No Yes If yes, what is the relationship? And to which adoptive parent? If the adopted person is currently living outside Canada, will the adopted person come to Canada to live within 6 months of being granted Canadian citizenship?

D

E

No

Yes

If yes, where? or which province?

6
A

DETAILS OF THE ADOPTED PERSON
Last name (surname/family name) at birth of the adopted person Given name(s) at birth of the adopted person

B

Last name (surname/family name) as indicated on birth certificate or adoption order (if different from A)

Given name(s) as indicated on birth certificate or adoption order (if different from A)

C

Has the name of the adopted person changed since birth or the adoption? Last name (surname/family name) as it appears on the legal change of name document

No

Yes

If yes, write name if different from A or B.

Given name(s) as it appears on the legal change of name document

D

Any other names used now or in the past Last name (surname/family name)

No

Yes

If yes, write name(s) and details. Given name(s) Write details (e.g. birth name, nickname, maiden name, etc.)

E

Full name as it appears on the adopted person's birth certificate in the adopted person's native language (e.g. Arabic, Cyrillic, Chinese, Korean, Japanese characters or Chinese commercial/telegraphic code).

F

Date of birth Sex

Day

Month

Year

Place of birth (city/town)

Province/Region of birth

Country of birth

G

H

Female

Male

Marital status

Single

Married

Common-law

Widowed

Divorced

Separated

I

Country (countries) where the adopted person has citizenship

Current passport or travel document number

Date issued
Year Month Day Year

Expiry date
Month Day

This passport or travel document will be used to travel to Canada. I don't know I don't know I don't know No No No Yes Yes Yes

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6
J

DETAILS OF THE ADOPTED PERSON (continued)
Details of the adopted person's biological family members

PAGE 3 OF 5

If known, you must provide the following details about each of the adopted person's family members (including biological father, biological mother and biological brothers and sisters). If you do not have enough space, provide details on a separate sheet of paper. FAMILY MEMBER Last name (surname/family name) Given name(s) Sex Date of birth Place of birth Town/City Country Country of citizenship Country of residence Other countries with permanent resident status Marital status Relationship with the adopted person
K
Day

FAMILY MEMBER

FAMILY MEMBER

Female
Month

Male
Year Day

Female
Month

Male
Year Day

Female
Month

Male
Year

Do you know where the adopted person lives? No Yes If yes, include the address: Apt./unit

L

The address is also required in the local language where the adopted person is living (e.g. Arabic, Cyrillic, Chinese, Korean, Japanese characters or Chinese commercial/ telegraphic code). Only if applicable.

No. & street

City/Town

Province/Territory

Postal code

Country

Name of the contact person/institution

M

Addresses of the adopted person Write all addresses where the adopted person stayed or lived during the past 10 years. Do not use post office (P.O.) box addresses. From Y M Y To M No. and street (do not use P.O. Box address) City/Town Province, state or district Country

PRESENT

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6
N

DETAILS OF THE ADOPTED PERSON (continued)

PAGE 4 OF 5

Personal history Write details on what the adopted person has been doing in the past 10 years, starting with the most recent information. Please also account for the adopted person's activities since turning age 13, should this period of time be longer than the last 10 years. Do not leave gaps. From Y M Y To M Activity (if applicable) City/Town and country Name of company, employer, school, facility, as applicable

PRESENT

7

DETAILS OF THE ADOPTIVE PARENT(S)
ADOPTIVE PARENT Last name (surname/family name) Given name(s) Other name(s) used (include birth name, maiden, previous married name(s), aliases and nicknames) ADOPTIVE PARENT

Country of birth Date of birth Single Widowed
Day Month Year Day Month Year

Marital status

Married Divorced

Common-law Separated

Single Widowed

Married Divorced

Common-law Separated

8
A

ADOPTIVE PARENT(S) ADDRESS DETAILS (or legal guardian) if different from section 4
Residential address
B

Home telephone no. Business telephone no.

Country code

Area code

No.

Country code

Area code

No.

No. & street

Apt./unit Cellular phone no.
Country code Area code No.

City/Town

Province/Territory Facsimile no.

Country code

Area code

No.

Postal code

Country E-mail address

9

INDIVIDUAL, FIRM OR ORGANIZATION WHO ASSISTED IN THE COMPLETION OF THIS APPLICATION
(The applicant does not complete this section) No Yes If yes, have the individual, firm or organization complete the following section 9.

Did you receive assistance in completing this form Name of individual who assisted in completing this application form Address

Name of firm, organization

Signature of INDIVIDUAL

Date
Year Month Day

CIT 0012 (04-2009) E

10 CANADIAN PASSPORT AND AUTHORIZATION TO RELEASE INFORMATION
A

PAGE 5 OF 5

I intend to apply for a Canadian passport for the adopted person at a Canadian Embassy, a High Commission or a Consulate outside Canada after the adopted person is granted Canadian citizenship. No Yes If yes, go to question 10 B. If no, go to section 11.

Note: This is not a passport application.
B

I authorize Citizenship and Immigration Canada to release the personal information regarding this application to the Canadian Embassy, High Commission or Consulate to facilitate the Canadian passport application process for the adopted person. No Yes If yes, sign this declaration.

Signature of adoptive parent/legal guardian or the adopted person (if 18 years of age or older)
Year Month Day

Printed name

Signature

Place

Date

11 DECLARATION AND SIGNATURES
I have read and understood the contents of this form. I declare that the information that I have provided in this form is true, complete and accurate. I understand that if I have made a false declaration or have otherwise provided false or misleading information or if I fail to declare all of the information material to the adopted person's application, the adopted person's application could be rejected or the adopted person could lose his or her Canadian citizenship. I understand that providing such false or misleading information, making a false declaration or failing to declare all information material to the adopted person's application could be an offence under the Citizenship Act. I hereby acknowledge that section 9 must be completed if an individual, firm or organization assisted me in the completion of this application. If section 9 is blank, I confirm that I completed this form myself without any help. Signature of adoptive parent/legal guardian or the adopted person (if 18 years of age or older)

(you must sign inside the white box in black ink only)
City
Year Month Day

Date

Children (14 years of age or older) must also sign this form:

(you must sign inside the white box in black ink only)
City
Year Month Day

Date

IMPORTANT NOTE: The application must be signed and dated before it is mailed. If your application is not signed and dated, it will be returned to you. You must make sure that all information you have entered is accurate and is up-to-date. Remember to make sure that you are eligible to apply on the day before you SIGN this application.

REMEMBER: You must submit one application form for each adopted person. If you are sending more than one application, send all of them together in one envelope. The applications will be processed together.

Protected Information Personal Information Bank CIC PPU 050
The information you provided on the application is collected under the authority of the Citizenship Act and is required to determine whether your citizenship application may be approved. The information will be retained in the Personal Information Bank CIC PPU 050 identified in Infosource. It may be shared with other organizations in accordance or disclosed, without notice or consent, pursuant to s. 8(2) of the Privacy Act. Under the Privacy Act and the Access to Information Act, individuals have the right to protection of, access to and correction of their personal information. Details of these matters are available at Infosource.gc.ca, at www.cic.gc.ca, at the local CIC offices, at the CIC Call Centre and at any Canadian public library.
CIT 0012 (04-2009) E