Statutory Declaration of Loss of Earnings

STATUTORY DECLARATION OF LOSS OF EARNINGS

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

1. My earnings are derived from ______.

2. During the period ______, I was unable to earn my usual income of ______.

3. As a result, I lost earnings in the amount of ______.

4. 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.

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

_______________________________ _______________________________

A Commissioner for taking Affidavits Signature of Declarant