Statutory Declaration of Date of Birth

STATUTORY DECLARATION OF DATE OF BIRTH

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

1. I was born on ______ at ______.

2. An official birth certificate is unavailable for the following reason: ______.

3. The following supports the facts stated above: ______.

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.

SWORN / DECLARED before me at the ______________________ of ______________________, in the Province of Ontario, this ______ day of ______________, 20______.

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant