Citizenship and Citoyenneté et PROTECTED WHEN COMPLETED - B

Immigration Canada Immigration Canada

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SOLEMN DECLARATION
CONCERNING A PERMANENT RESIDENT CARD THAT WAS LOST, STOLEN,
DESTROYED OR NEVER RECEIVED
ALL QUESTIONS MUST BE ANSWERED. IF SOME QUESTIONS DO NOT APPLY TO YOU, ANSWER "N/A" ("NOT APPLICABLE").
Surname (Family name) Given name(s) Client ID number
GEORGE ROSHNI 1108288975

1. Details (YYYY-MM-DD) City/Town Country

1991-07-11 at COCHIN INDIA
of birth

2. Permanent address:
No. and street
3551 ELLESMERE ROAD
Apt. no. City Province Postal code Permanent Resident Card (PR Card) number (if applicable):
TORONTO ON M1C1H5
Home Telephone number (Area code and number) Business Telephone no. (Area code and number) Ext.
(437) 989-2336

3. My Permanent Resident Card (PR Card) was: Lost Stolen Destroyed ✔ Never received

On or (YYYY-MM-DD) City/Town Country

at
about

Under the following circumstances (full information must be provided below):

4. I have made the following efforts to locate this document (if applicable indicate police authorities notified and attach a copy of police report or incident report number):

5. Should I ever regain possession of the original document, I promise to return it immediately to a Citizenship and Immigration Centre or, if I am abroad, to the nearest
Canadian Embassy, Consulate or High Commission.

I solemnly declare that the information I have provided is true, that it is of the same force and effect as if made under oath, and that it was freely given. I authorize the
department of Citizenship and Immigration Canada to verify the information I have provided. I also understand that the provision of any false or misleading information
may lead to prosecution in accordance with Section 127 of the Immigration and Refugee Protection Act.

(YYYY-MM-DD)
Signature
of declarant
► Date ►

Signature (YYYY-MM-DD)
of parent or guardian
if declarant is under
► Date ►
18 years of age

To report a PR Card that was lost, stolen, destroyed or never received, immediately submit this completed and signed form to Citizenship and Immigration
Canada by one of the following methods:

Mail it to the PR Card Processing Centre

P.O. Box 9000
Sydney, Nova Scotia
B1P 6K7

or fax it to the PR Card Processing Centre at 1-902-564-3148

IMM 5451 (09-2003) E (DISPONIBLE EN FRANÇAIS - IMM 5451 F)