Affidavits
Statutory Declaration of Loss of Earnings
A sworn declaration of income you lost — used to support an insurance, accident, or compensation claim. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
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Word files are editable. Review any changes carefully before signing or uploading.
Also known as
- Lost Income Affidavit
- Loss of Wages Declaration
- Declaration of Lost Earnings
+2 more names
- Sworn Statement of Loss of Income
- Loss of Earnings Affidavit
STATUTORY DECLARATION OF LOSS OF EARNINGS
I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:
Employer or other source of my earnings (if specified):
During the period ______, I was unable to earn my usual income of ______.
As a result, I lost earnings in the amount of ______.
The loss of earnings occurred for the following reason: ______.
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.
Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.
______________________________ | ______________________________ |
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- General template, not legal advice
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Statutory Declaration of Loss of Earnings
A compact preview of this template
01Your Information
Your full legal name
Employer or source of earnings
Your full address
STATUTORY DECLARATION OF LOSS OF EARNINGS
I, ______, of ______, in the Province of Ontario, SOLEMNLY DECLARE that:
Employer or other source of my earnings (if specified):
During the period ______, I was unable to earn my usual income of ______.
As a result, I lost earnings in the amount of ______.
The loss of earnings occurred for the following reason: ______.
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.
Signed and sworn (or affirmed/declared) before me by videoconference in Ottawa, Ontario, while the Affiant(s)/Declarant(s) were located in ______________________, on ______________________, pursuant to O. Reg. 431/20, and Electronic Commerce Act, 2000.
______________________________ | ______________________________ |
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How it works
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Overview
About this document
- 01
What is a loss of earnings declaration?
It is a sworn statement — also called a lost income affidavit or loss of wages declaration — setting out the income you were unable to earn and why, over the period it covers.
Insurers and claims processes use it to assess a claim for lost income.
- 02
When you might need one
It supports claims involving lost income.
- An insurance or accident claim that includes lost income.
- A compensation or disability claim requiring proof of lost earnings.
- Confirming income you could not earn due to an event.
- 03
What to include
State the period, the income you lost, and the reason. Keep supporting records — pay information, a doctor’s note, or employer confirmation — available, as the insurer or process may request them.
- 04
How to notarize a statutory declaration of loss of earnings in Ontario
After you fill in your statutory declaration of loss of earnings and download the PDF, do not sign it in advance. A sworn document must be signed in front of a notary public or commissioner for taking affidavits, who administers your oath or solemn affirmation first.
Minute Notary commissions your statutory declaration of loss of earnings online by secure video, under Ontario's remote commissioning rules (O. Reg. 431/20), or in person in Ottawa. Bring valid government-issued photo identification so we can verify your identity before applying the notary seal.
Good to know
Before you fill it in.
Short notes from our notary on this template. Worth a minute before you start.
- 01
Reviewed for use in Ontario by a notary public and commissioner for taking affidavits.
- 02
Fill it in online for free and download a ready-to-sign PDF — no account required.
- 03
Sign in front of the notary, who administers your oath or affirmation and applies the seal.
- 04
Notarize online by video across Ontario, or in person in Ottawa.
Frequently asked
Questions about the Statutory Declaration of Loss of Earnings
- When do I need a loss of earnings declaration?
- To support an insurance, accident, compensation, or disability claim that includes income you were unable to earn.
- What should it include?
- The period, the income lost, and the reason. Keep pay records, a doctor’s note, or employer confirmation available.
- Can I notarize it online in Ontario?
- Yes. You can swear it online by video under Ontario’s remote commissioning rules, or in person in Ottawa with Minute Notary.
- Does it guarantee my claim?
- No. It supports your claim; the insurer or process decides under its own rules and may ask for more records.
Keep exploring
Related templates
Other documents for identity & personal status.
- 01Statutory Declaration of No Income
A sworn declaration confirming that you have no income for a period — used to support benefit, subsidy, fee-waiver, or sponsorship applications. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
Fill it out - 02Affidavit of Lost Document
A sworn affidavit confirming that an important document has been lost — used to support a request for a replacement or to rely on a copy. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
Fill it out - 03Statutory Declaration of Loss of a Receipt
A sworn declaration that a receipt has been lost — used to support a claim, reimbursement, warranty, or expense where the original receipt is unavailable. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
Fill it out - 04Statutory Declaration of Lost or Stolen Identification
A sworn declaration that a piece of government identification has been lost or stolen — often required before a replacement is issued. Fill it in online, download a ready-to-sign PDF, and notarize in Ontario.
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