You are on page 1of 2

PROTECTED WHEN COMPLETED B

PAGE 1 OF 2

DECLARATION
concerning a lost, stolen, inaccessible, damaged or found Canadian travel document
WARNING to applicantAny false or misleading statement on this form or relating to any document in support of your travel document application,
including concealment of any material fact, may lead to refusal to issue or revocation of a travel document and be grounds for criminal prosecution.
TYPE OR PRINT IN CAPITAL LETTERS using black or dark blue ink.

PERSONAL INFORMATION AS INDICATED ON MOST RECENT CANADIAN TRAVEL DOCUMENT

The travel document was issued in:

My name

Child's name

Surname (last name)

Given name(s)

Date of birth
Year

Month

Place of birth
Day
City

Document number (if known)

Prov./Ter./State (if applicable)

Country

Date of issue (if known)


Year

Month

Place of issue (if known)

Day
City

Signature of applicant

Country

Date

Signed at

Year

Month

Day
City

Country

No Continue to section 2

Is the travel document being submitted with your declaration?

Yes Go to section 3

INFORMATION CONCERNING A VALID CANADIAN TRAVEL DOCUMENT NO LONGER IN MY POSSESSION


2 Note: Incomplete descriptions may result in the delay or refusal of your application. If insufficient space, attach a separate signed and dated sheet.
The travel document listed in section 1 is no longer in my possession because (please provide a detailed explanation as to why you are not
submitting the travel document and what has happened to it)

I have made the following efforts to recover this travel document (please explain)

Date this document was lost, stolen or became inaccessible

This document was last used on


Year

Month

Year

Location
City

Country

Report number

Yes

Date of report

No

Please provide the reason for not filing a police report

Year

Month

Day

Were any other provincial or federal identification documents lost or stolen?

PPTC 203E (2014-11) R2

Day

Day

Was a police report filed?

Yes

Month

No

(AUSSI DISPONIBLE EN FRANAIS PPTC 203F)

Name of police service

PAGE 2 OF 2

INFORMATION CONCERNING A DAMAGED OR FOUND CANADIAN TRAVEL DOCUMENT

Note: If insufficient space, attach a separate signed and dated sheet.

Detailed circumstance of how the travel document was damaged or found

Explain why you are applying for a replacement travel document

Location

Date travel document was damaged or found


Year

Month

Day
City

Country

Reminder: A travel document application form must also be completed if a replacement travel document is required. Please note that the travel
document specified in this form cannot be used for the simplified renewal process.

DECLARATION OF APPLICANT

4
Surname (last name)

Given name(s)

Daytime telephone number

Date of birth
Year

Month

Day

DECLARATIONI solemnly declare that, to my knowledge, the statements made in this declaration are true. Should I ever regain possession of
the Canadian travel document reported in section 1, I will return it immediately to the Passport Program or if abroad to the nearest Government of
Canada office. I acknowledge that a Canadian travel document once reported lost, stolen, inaccessible, damaged or found is no longer
valid and is NOT to be used for any travel. I understand multiple occurrences of Lost/Stolen or Damaged travel documents may result in either
the refusal to issue a replacement travel document, or if approved, a severely limited validity of the replacement travel document. I also
acknowledge that additional requirements may apply, such as demonstrating the need to be issued a travel document. I declare that I have read
and understood the WARNING to applicant at the top of page 1.
Signature of applicant

Signed at

Date
Year

Month

Day
City

Country

FOR OFFICE USE ONLY


Based on the information provided by the applicant on this form, the travel document has been identified as
Lost

Stolen

Damaged

Mutilated

Inaccessible

Found

Name of officer who reviewed the above information (stamp recommended)

Date
Year

Travel document number

Date of issue
Year

Month

Day

Place of issue
Day
City

To obtain the most recent version of this form, visit our website at passportcanada.gc.ca.

PPTC 203E (2014-11) R2

Month

Country