Statutory Declaration of Address History

STATUTORY DECLARATION OF ADDRESS HISTORY

I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:

1. For the period covering ______, I have lived at the following addresses, with the dates shown: ______.

2. To the best of my knowledge and recollection, the above is a complete and accurate record of the addresses where I have lived during that period, with no gaps.

3. I make this declaration for the following purpose: ______.

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 the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant