RCMP-GRC 2010E: Statutory declaration

Protected "B" when completed

This form is required for purposes of the Royal Canadian Mounted Police Superannuation Act and should be completed by the survivor or other person(s) having custody and control of dependant children.

Pension number

Province of

Country of

In the matter of the Royal Canadian Mounted Police Superannuation Act

I, (Name in full)

of (Complete address)

in the county of

province of

do solemnly declare:

that I am the (Relation to deceased)

of the late (Name of deceased public servant)

of (Complete address)

in the County of2

Province of2

That the dependant children (include stepchildren and adopted children) now alive of the said late plan member, and their birth dates are as follows:

Live dependant child 1 Name

Live dependant child 1 Date of birth ( YYYYMMDD)

Live dependant child 2 Name

Live dependant child 2 Date of birth ( YYYYMMDD)

Live dependant child 3 Name

Live dependant child 3 Date of birth ( YYYYMMDD)

Live dependant child 4 Name

Live dependant child 4 Date of birth ( YYYYMMDD)

That I have custody and control of all the above-named dependant children, or the following dependant children:

Custody of dependant child 1 Name

Custody of dependant child 1 Date of birth ( YYYYMMDD)

Custody of dependant child 2 Name

Custody of dependant child 2 Date of birth ( YYYYMMDD)

Custody of dependant child 3 Name

Custody of dependant child 3 Date of birth ( YYYYMMDD)

Custody of dependant child 4 Name

Custody of dependant child 4 Date of birth ( YYYYMMDD)

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

Declared before me at (city, town or village)

In the province of

on this day

of (Month)

(Year)

(Indicate whether Justice of the Peace, Commissioner for oaths, Notary, or other authorized person.)

Signature of declarant

Official Title (if applicable)

Send completed declarations to:

Organization:: Government of Canada Pension Centre—Mail facility
Address:: 150 Dion Boulevard
PO Box 8500
Matane QC G4W 0E2

RCMP- GRC 2010E (2014-07-001)

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Date modified:: 2018-10-22

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RCMP-GRC 2010E: Statutory declaration