RCMP-GRC 2483E: Statutory declaration

Statutory declaration PDF, 316KB)

Protected "B" when completed

In the matter of provision of pension benefits Information under the Pension Benefits Division Act

Privacy notice

Complete either Part 1 or Part 2, and complete Part 3

Part 1 : Married - Complete this section only if the member and the spouse are or were married.

Part 1

(Check the applicable box)

Part 2 : Not married - Complete this section only if the member and the common-law partner were not married but have cohabited in a conjugal relationship for at least one year.

Part 2

(Check the applicable box)

Part 3 : During the period we were married or we lived together in a conjugal relationship, as noted above

Part 3

(Check the applicable box)

(Indicate all breaks - Attach a separate sheet if necessary)

I make this declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.

Carefully read instructions before completing

Every person who knowingly makes a false or misleading representation in any application or other proceeding under the PBDA is guilty of an offence punishable on summary conviction.

RCMP- GRC 2483E (2014-07-001)

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