Fillable Printable Sworn Statement – Proof Of Residence
Fillable Printable Sworn Statement – Proof Of Residence
Sworn Statement – Proof Of Residence
SWORN STATEMENT – PROOF OF RESIDENCE
SEE INSTRUCTIONS ON REVERSE SIDE
Section
To be completed by the person stating, under oath, the place of residence of the card applicant
I, the undersigned, , domiciled at
,
and whose phone number is , solemnly declare that
is currently domiciled at the above-mentioned address or at (if the applicant's address is different from yours)
and that I am the landlord, the landlord's representative or the tenant whose name appears on the lease.
First and last names of the landlord, the landlord's representative or the tenant whose name appears on the lease
Number, street, apartment, municipality and postal code
Area code
First and last names of the card applicant
Number, street, apartment, municipality and postal code
Section
To be completed before a commissioner for oaths
I solemnly declare that all the information in this statement is accurate and complete.
First and last names in block letters
Signature of the person making the sworn statement
X
Sworn before me at .
Location
First and last names of the commissioner Commissioner number or title
Signature of the commissioner for oaths
Date
Seal
This statement is valid for 45 days from the date it is signed by the commissioner for oaths.
4249 365 15/07
INSTRUCTIONS
IMPORTANT
A person who willingly misleads, declares or attests under oath a fact that he/she knows to be inaccurate is liable to be prosecuted
for perjury under the Criminal Code of Canada. The Régie de l'assurance maladie du Québec is entitled to verify the authenticity
of the declarations made in this statement.
Section to be completed by the landlord, the landlord's representative or the tenant whose name appears
on the lease, who is stating, under oath, the place of residence of the card applicant.
Enter :
• your first and last names, address and phone number
• the name of the person for whom the proof of residence must be provided
• the residential address of this person (if different from that of your own domicile)
Section to be completed before a commissioner for oaths.
Go to a commissioner's office for the signing of the sworn statement. Remember to take this form and an ID document with you.
Persons authorized to act in the capacity of commissioner for oaths include:
• commissioners for oaths appointed by the Ministère de la Justice (please refer to www.assermentation.justice.gouv.qc.ca to find
the commissioner for oaths nearest you)
• certain employees at the reception desks of the Régie de l'assurance maladie du Québec
• lawyers and notaries duly registered with the Barreau du Québec or the Chambre des notaires du Québec and justices of the
peace, throughout Québec
• the mayor, councillor, clerk or secretary-treasurer of a municipality, within the territory of his/her municipality
• clerks of Québec courts and their assistants, within the judicial district where they are appointed
• the secretary general, assistant secretaries general and assistant secretaries of the National Assembly, throughout Québec
• agents in certain Services Québec offices (call to confirm before going there)
A fee may be required of the person having to provide proof of residence for the swearing-in.
