Statutory Declaration of Caregiver for a Dependent Adult

STATUTORY DECLARATION OF CAREGIVER FOR A DEPENDENT ADULT

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

1. I provide care and support to ______, who is my ______.

2. I have provided this care since ______. The care and support I provide includes: ______.

3. Our living arrangement is: ______.

4. I make this declaration to support a care, credit, or benefit matter, 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