Free CIT 0457E - Canada

Fillable Form
Citizenship and Immigration Canada Citoyenneté et Immigration Canada
PROTECTED WHEN COMPLETED - B

SOLEMN DECLARATION
CONCERNING A CITIZENSHIP CERTIFICATE THAT WAS LOST, STOLEN, DESTROYED OR NEVER RECEIVED
ALL QUESTIONS MUST BE ANSWERED. IF SOME QUESTIONS DO NOT APPLY TO YOU, ANSWER "N/A" ("NOT APPLICABLE"). Surname (Family name) Given name(s) File number

1

Details of birth

Day

Month

Year

City/Town at

Country

2

Permanent address: No. and street

Apt. no.

City

Province

Postal code

Citizenship certificate number (if applicable):

Home telephone number
3

Area code

Number

(

)

Lost City/Town at

Business telephone number Stolen

Area code

Number

Extension

(

)
Destroyed Country

Never received

My citizenship certificate was: On or about
Day Month Year

Under the following circumstances (full information must be provided below):

4

I have made the following efforts to locate this document (if applicable, indicate police authorities notified and attach a copy of police report or incident report number):

5

Should I ever regain possession of the original document, I promise to return it immediately to a Citizenship and Immigration Canada office or, if I am abroad, to the nearest Canadian Embassy, Consulate or High Commission. I solemnly declare that the information I have provided is true, that it is of the same force and effect as if made under oath, and that it was freely given. I authorize the department of Citizenship and Immigration Canada to verify the information I have provided. I also understand that the provision of any false or misleading information may lead to prosecution in accordance with section 29 of the Citizenship Act. Signature of declarant Signature of parent or guardian if declarant is under 18 years of age
Day Month Year

Date

Day

Month

Year

Date

To report a citizenship certificate that was lost, stolen, destroyed or never received, immediately submit this completed and signed form to Citizenship and Immigration Canada by one of the following methods: Mail it to the Citizenship and Immigration Canada Case Processing Centre - Sydney P.O. Box 7000 Sydney, Nova Scotia B1P 6V6

or fax it to the Case Processing Centre at 1-902-564-2781
CIT 0457 (03-2005) E

(DISPONIBLE EN FRANÇAIS - CIT 0457 F)