Ministre de lImmigration et des Communauts culturelles A-0522-PA (2011-08)

CONTRACT RESPECTING FINANCIAL SELF-SUFFICIENCYLive-in caregiver and person authorized to apply for permanent residence in Canadaon humanitarian grounds

INSTRUCTIONS

Who must fill out this form?

A live-in caregiver or person authorized by Citizenship and Immigration Canada to apply for permanent residence in Canada on humanitariangrounds, who is currently living in Qubec and applies for a Certificat de slection du Qubec (Qubec selection certificate) under the SkilledWorker subclass.

All other persons must complete the form entitled Contract respecting Financial Self-sufficiency - Principal Applicant (excluding live-incaregivers and persons authorized to apply for permanent residence in Canada on humanitarian grounds).

What is the Contract respecting financial self-sufficiency?

The Contract respecting financial self-sufficiency is a legal act by which you undertake, for the entire term of the contract, to provide for yourbasic needs and, where applicable, those of your spouse or de facto spouse and your dependent children (including those who are Canadiancitizens) who accompany you to and live in Qubec. The term of the contract is three months starting on the issue date of your Quebecselection certificate. Basic needs include food, clothing, personal necessities and housing-related expenses.

You must sign this contract or else your application for a selection certificate will not be accepted. For more information, see the Actrespecting immigration to Qubec (R.S.Q., c. I-0.2) and the Regulation respecting the selection of foreign nationals (R.R.Q. 1981, c. M-23.1, r. 2).

How to fill out this form

Section A identifies you and, where applicable, your spouse or de facto spouse and dependent children (including Canadian citizens) who areaccompanying you: Answer the questions accurately.

Section B of the contract: Read the contract carefully and sign it. Don't forget to enter your gross annual income at Point 1.

Ministre de lImmigration et des Communauts culturelles A-0522-PA (2011-08)Page 1 of 2

Section AIDENTIFICATION OF THE PRINCIPAL APPLICANT

IDENTIFICATION OF ACCOMPANYING SPOUSE OR DE FACTO SPOUSEAND DEPENDENT CHILDREN WHO ARE LIVING IN QUEBEC

CONTRACT RESPECTING FINANCIAL SELF-SUFFICIENCYLive-in caregiver and person authorized to apply for permanent residence in Canadaon humanitarian grounds

Reserved for Administration

Individual Reference No. :

File No. :

Family name at birth: ____________________________________________________________ First name: ____________________________________________________

Family name after marriage (where applicable) : ______________________________________ Sex: F M Date of birth: ____________________________

Marital status: Single Married De facto spouse Separated Divorced Marriage annulled Widowed

Residence address: ________________________________________________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________ Telephone number: ______________________________________________

Year / Month / Day

Family Name(at birth) FIRST NAME SEX

DATE OFBIRTH

Year / Month / Day

ADDRESS(if different from the principal applicant)

A - Spouse or de facto spouse

1

2

3

4

5

6

B - Dependent children (including children who are Canadian citizens)

I acknowledge having read the information on this form and I understand the nature and scope of the contract respecting financial self-sufficiency. Consequently:

1. I declare that I have gross annual income of CA $ _______________________ .

2. I undertake, for the term of this contract, which is three months starting on the issue date of my Qubec selection certificate, to provide for my basic needs andthose of other persons identified in Section A.

3. I undertake to reimburse the Government of Qubec for any amount that it may pay me or other persons identified in Section A, in the form of last resort financialassistance, in accordance with applicable legislation, throughout the full term of the contract.

4. I authorize the Ministre de l'Immigration et des Communauts culturelles to transmit information about this contract to the Ministre de l'Emploi et de la Solidaritsociale, if any application is made for last resort financial assistance for myself or for any persons identified in Section A.

In witness whereof, I have signed at ___________________________________________________________ on ____________________________

__________________________________________________________________________________________________________________

Section BCONTRACT

Signature of the principal applicant

A-0522-PA (2011-08)Page 2 of 2

Please keep a signed copy of this form and return the other signed copywith your application for a Qubec selection certificate.

Year / Month / DayCity