Free CIT 0496E - Canada

Fillable Form
Citizenship and Immigration Canada Citoyenneté et Immigration Canada UCI no. FOR OFFICIAL USE ONLY Case ID Former Act
PAGE 1 OF 4

APPLICATION TO RENOUNCE CANADIAN CITIZENSHIP - R7.1 (for certain persons who acquired citizenship on April 17, 2009)

3(1)(f) Return original document(s) Signature Renunciation effective date Notify: Send to:

3(1)(g) Approved
Y Date M D

Y

M

D

Before you start, read the instructions Please PRINT in ink or TYPE
FOR OFFICIAL USE ONLY

Protected when completed

1 I want service in 2 Have you ever had a certificate of Canadian
citizenship or naturalization? My certificate of Canadian citizenship is:

English

OR

French

Please check (

) one

No

Yes

Certificate Number

enclosed

stolen

lost

destroyed

Was the theft/loss reported to police?

No

Yes

Details

Note: It is illegal to have a certificate of citizenship or naturalization once you have renounced your Canadian citizenship. If you have any certificate of citizenship or naturalization or any pink transmission copy of a certificate, you have to send it back.

3A Name to appear on your document
(subject to approval by Citizenship and Immigration Canada)

Last name (surname/family name)

Given name(s)

B List any other names (include birth
name, maiden, previous married name(s), aliases and nicknames). These names will not appear on your citizenship certificate.
Last name (surname/family name) Given name(s)

Use another piece of paper if you need more space.

4

Day

Month

Year

City, town, etc.

Country

A Birth details Date B Personal
information Marital status Single Sex Male OR Female

Place Colour of eyes Divorced Separated

Height Married

cm OR Commonlaw

ft Widowed

in

(AUSSI DISPONIBLE EN FRANÇAIS - CIT 0496 F)
CIT 0496 (04-2009) E

AVAILABLE ON CIC WEB SITE AT: http://www.cic.gc.ca

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5

A Home address
Postal code

B Mailing address
(if different from home address) Postal code Home ( ) Work ( Cell ( ) ) Name of country or countries and attach proof. Ext.

C Telephone number(s)

6

I am a citizen or a national of a country other than Canada. IF NO I will become a citizen of

No

Yes

once I renounce my Canadian citizenship. (attach proof)

7

If you are a woman and married before January 1, 1947, answer the following questions. If you married for the first time on or after January 1, 1947, this question does not apply to you. Go to Section 8. Information on your husband (Provide details of every marriage before 1947.) Husband's surname/last name Given name(s)
Day Month Year

Husband's country of birth Country of marriage Is your husband a Canadian citizen? Number on husband's citizenship certificate (if applicable) Please use another piece of paper if you need more space to list other marriages. No Yes By birth OR

Date of birth
Year Month Day

Date of marriage Other
Year Month Day

Date

8

ABSENCES FROM CANADA Did you leave Canada for 1 year or longer before 1977?
FROM
Y M D Y

No

Yes

Give details below:

TO
M D

DESTINATION What country did you go to?

REASON Why did you go to this country?

Please use another piece of paper if you need more space.

9

Have you ever lived in Canada?

No

Yes

If yes, on what date did you enter Canada to live? OR

Year

Month

Day

Since birth

CIT 0496 (04-2009) E

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10 APPLICANT'S PARENTS
Relationship to you

Answer all of the following questions: Natural father FATHER Adoptive father Natural mother MOTHER Maiden name Adoptive mother

Surname/Last name Given name(s)
D M Y

D

M

Y

Country and date of birth Married in what country Additional information How did he obtain Canadian citizenship? Date of marriage
Y M D

How did she obtain Canadian citizenship?

Did he leave Canada for more than 1 year before 1977? No
From Y M

Did she leave Canada for more than 1 year before 1977? No Yes
To Y M Destination (Country)

Yes
To Y M Destination (Country)

From Y M

Is he or was he a citizen of a country other than Canada? No Yes Give details (country, date and how citizenship was obtained)

Is she or was she a citizen of a country other than Canada? No Yes Give details (country, date and how citizenship was obtained)

Was he employed in Canada by a foreign government Was she employed in Canada by a foreign government or international agency? or international agency? No Yes Give details No Yes Give details

If father was born in Canada, was one of his parents If mother was born in Canada, was one of her parents employed by a foreign government or international employed by a foreign government or international agency? agency? No Yes Give details No Yes Give details

CIT 0496 (04-2009) E

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11 SIGNATURE OF APPLICANT
I agree to advise Citizenship and Immigration Canada if any information on this form changes before the processing of my application is complete. I understand the contents of this form and the significance of renouncing my Canadian citizenship. I declare that the information provided is true, correct, and complete, and that the photograph enclosed is a true likeness of me. I understand that, if I make a false declaration or fail to disclose all information material to my application, my confirmation of renunciation could be taken away and my renunciation deemed to have no effect and I could be charged under the Citizenship Act. I hereby acknowledge that section 12 below must be completed if an individual, firm or organization assisted me in the completion of this application. If section 12 is blank, I confirm that I completed this form myself without any help.
Signature of applicant (you must sign inside the white box in black ink only)

Year

Month

Day

City

Date

WHO ASSISTED IN THE COMPLETION OF THIS APPLICATION 12 INDIVIDUAL, FIRM OR ORGANIZATIONsection) (The applicant does not complete this

Did you receive assistance in completing this form? No Yes

If yes, have the individual, firm or organizationcomplete the following section.
Name of individual who assisted in completing this application form Address
Date
Year Month Day

Name of firm, organization

Signature of INDIVIDUAL

REMEMBER: IF YOU ARE SENDING MORE THAN ONE APPLICATION, SEND ALL OF THEM TOGETHER IN ONE ENVELOPE. THE APPLICATIONS WILL BE PROCESSED TOGETHER.

FAILURE TO INCLUDE THE NECESSARY DOCUMENTATION WILL RESULT IN DELAYS IN PROCESSING YOUR APPLICATION.

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 0496 (04-2009) E