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CIT 0496 (06-2019) E

PROTECTED WHEN COMPLETED - B

(DISPONIBLE EN FRANÇAIS - CIT 0496 F)AVAILABLE ON CIC WEB SITE AT: http://www.cic.gc.ca

FOR OFFICIAL USE ONLY

APPLICATION TO RENOUNCE CANADIAN CITIZENSHIP - R7.1 (for certain persons who acquired citizenship under amendments to the Citizenship Act in 2009 or 2015)

UCI no. Case ID

Current Act

Return original document(s) Approved

Signature and renunciation effective date

Notify:

Send to:

Before you start, read the instructions Please PRINT in ink or TYPE

Date (YYYY-MM-DD)

FOR OFFICIAL USE ONLY

1 I want service in English FrenchOR onePlease check

2No Yes ►

Have you ever had a certificate of Canadian citizenship or naturalization?

Certificate Number

Given name(s)

3 A Name to appear on your document (subject to approval by Citizenship and Immigration Canada)

Last name (surname/family name)

Note: It is illegal to have a certificate of citizenship or naturalization once you have renounced your Canadian citizenship. If you have any certificate of citizenship or naturalization or any pink transmission copy of a certificate, you have to send it back.

Was the theft/loss reported to police?

No Yes ► Details

My certificate of Canadian citizenship is:

enclosed stolen lost destroyed

B List any other names (include birth name, maiden, previous married name(s), aliases and nicknames). These names will not appear on your citizenship certificate.

Last name (surname/family name) Given name(s)

Use another piece of paper if you need more space.

4 A Birth detailsDate (YYYY-MM-DD)

PlaceCity, town, etc. Country or territory

B Personal information

Gender ► F Female

M Male

X Another gender ► Height cm OR ft in ► Colour of

eyes

Marital status ► Single Married Common-law Widowed Divorced Separated

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CIT 0496 (06-2019) E

5 A Home address

Postal code

B Mailing address(if different from home address) Postal code

C Telephone number(s) Home Work Ext. Cell

E-mail address: (Indicating an e-mail address will authorize all correspondence, including file and personal information, to be sent to the e-mail address you specify.)

6 A I am a citizen or a national of a country or territory other than Canada. ► No Yes ► Name of country or

territory and attach proof.

IF NO I will become a citizen of

once I renounce my Canadian citizenship. (attach proof)

B I hereby declare that I wish to renounce my Canadian citizenship for the following reasons:

IF YOU RECEIVED A CITIZENSHIP CERTIFICATE ON OR AFTER FEBRUARY 15, 1977, GO TO SECTION 12

7 If you are a woman and married before January 1, 1947, answer the following questions. If you married for the first time on or after January 1, 1947, this question does not apply to you. Go to Section 8.

Information on your husband (Provide details of every

Husband's surname/last name

marriage before 1947.) Given name(s)

Husband's country or territory of birth ► Date of birth(YYYY-MM-DD)

Country or territory of marriage ► Date of marriage(YYYY-MM-DD)

Is your husband a Canadian citizen? No Yes ► By birth OR Other ►

Number on husband's citizenship certificate (if applicable) ► Date

(YYYY-MM-DD)

Please use another piece of paper if you need more space to list other marriages.

8 ABSENCES FROM CANADA

Did you leave Canada for 1 year or longer before 1977? No Yes ► Give details below:

FROM (YYYY-MM-DD)

TO (YYYY-MM-DD)

DESTINATION What country or territory did

you go to?

REASON Why did you go to this country or territory?

Please use another piece of paper if you need more space.

9 Have you ever lived in Canada? No Yes ► If yes, on what date did you enter Canada to live?

(YYYY-MM-DD)OR Since birth

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CIT 0496 (06-2019) E

10 APPLICANT'S PARENTS Answer all of the following questions:

PARENT Relationship to you Natural parent Adoptive parentSurname/Last name Given name(s)

Other name used (name at birth, maiden name)

Country or territory of birth Date of birth (YYYY-MM-DD) Married in what country or territory Date of marriage (YYYY-MM-DD)

Additional information

How did this parent obtain Canadian citizenship?

Did this parent leave Canada for more than 1 year before 1977? No Yes From (YYYY-MM)

To (YYYY-MM) Destination (Country or territory)

Is this parent or was this parent a citizen of a country or territory other than Canada? No Yes ► Give details

(country or territory, date and how citizenship was obtained)

Was this parent employed in Canada by a foreign government or international agency? No Yes ► Give details

If the parent was born in Canada, was one of your grandparents employed by a foreign government or international agency? No Yes ► Give details

OTHER PARENT Relationship to you Natural parent Adoptive parentSurname/Last name Given name(s)

Other name used (name at birth, maiden name)

Country or territory of birth Date of birth (YYYY-MM-DD) Married in what country or territory Date of marriage (YYYY-MM-DD)

Additional information

How did this parent obtain Canadian citizenship?

Did this parent leave Canada for more than 1 year before 1977? No Yes From (YYYY-MM)

To (YYYY-MM) Destination (Country or territory)

Is this parent or was this parent a citizen of a country or territory other than Canada? No Yes ► Give details

(country or territory, date and how citizenship was obtained)

Was this parent employed in Canada by a foreign government or international agency? No Yes ► Give details

If the parent was born in Canada, was one of your grandparents employed by a foreign government or international agency? No Yes ► Give details

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CIT 0496 (06-2019) E

11 APPOINTMENT OF A REPRESENTATIVE

Are you appointing an individual, firm or organization as your representative? ► No Yes ► If yes, the Use of a Representative form (IMM 5476) must be completed and included with your application.

12 SIGNATURE OF APPLICANT

I agree to advise Citizenship and Immigration Canada (CIC) if any information on this form changes before the processing of my application is complete. I understand the content of this form and the significance of renouncing my Canadian citizenship. I declare that the information provided is true, correct and complete, and that the photograph enclosed is a true likeness of me. I understand that if I, or someone on my behalf, make a false representation, commit fraud, or conceal any material circumstances relevant to my application, my application could be denied, my renunciation document could be taken away, and I could be charged with an offence as provided under the Citizenship Act or the Criminal Code.

Signature of applicant (you must sign inside the white box in black ink only)

City

(YYYY-MM-DD)

Date

REMEMBER:

IF YOU ARE SENDING MORE THAN ONE APPLICATION, SEND ALL OF THEM TOGETHER IN ONE ENVELOPE. THE APPLICATIONS WILL BE PROCESSED TOGETHER.

FAILURE TO INCLUDE THE NECESSARY DOCUMENTATION WILL RESULT IN YOUR APPLICATION BEING RETURNED.

Protected Information Personal Information Bank CIC PPU 050

The information you provided on the application is collected under the authority of the Citizenship Act and is required to determine whether your citizenship application may be approved. The information will be retained in the Personal Information Bank CIC PPU 050 identified in Infosource. It may be shared with other organizations in accordance or disclosed, without notice or consent, pursuant to the Citizenship Regulations or s. 8(2) of the Privacy Act. Under the Privacy Act and the Access to Information Act, individuals have the right to protection of, access to and correction of their personal information. Details of these matters are available at Infosource.gc.ca, at www.cic.gc.ca, at the local CIC offices, at the CIC Call Centre and at any Canadian public library.