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Statutory Declaration of Tax Residency

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STATUTORY DECLARATION OF TAX RESIDENCY

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

  1. I am the person named above, born on .

  2. For tax purposes, my status is: ______.

  3. Where I am resident in another country for tax purposes, that country is , and my tax identification number is .

  4. This status has applied since , to the best of my knowledge.

  5. 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