RCMP-GRC 2484E: Statutory declaration

Statutory declaration PDF, 321KB)

Protected "B" when completed

In the matter of Provision of pension benefits Information Under the Pension Benefits Division Act

Privacy notice

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

Section 1 : Married - Complete this section only if the plan member and the spouse were married and are now either separated or divorced

(Check the applicable box) Section 1

Section 2 : Not married - Complete this section only if the plan member and the common-law partner were not married, but have cohabited in a conjugal relationship for at least one year and are now living separate and apart.

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

(Check the applicable box) Section 3
I make this declaration conscientiously believing it to be true and knowing that it has the same effect as if made under oath.


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 2484E (2014-07-001)

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