Form IMM 5521 - Application for a Protected Person Status Document

Citizenship andImmigration CanadaCitoyenneté etImmigration CanadaAPPLICATION FOR APROTECTED PERSON STATUS DOCUMENTPROTECTED WHEN COMPLETED - BPAGE 1 OF 2For office use onlyClient ID NumberYour full nameFamily nameGiven name(s)I wantserviceinEnglishFrench1. Other names you are or have been using(including name at birth, previous married names, aliases)11. Your residential address, if different from your mailing addressNo. andstreetApt.numberCityProvincePostalCode2. Your date of birthDayMonthYear12. Your telephone numbersArea codeNumber3. Place of BirthAt home( )Town/CityAlternative( )Country4, Yourcountry ofcitizenship13. Determination of protected person status(or Convention refugee status)Date ofdeterminationDayMonthYear5. Your countryof last permanentresidenceCityProvince6. Your sexMaleFemale7. Your height cm ORft in14. Are you physicallypresent in Canada?YesNo8. Your eyecolour9. YourcurrentmaritalstatusNevermarriedLegallyseparatedIf you are married, date of yourmarriageMarriedDivorcedDay MonthYearWidowed15. Have you applied for permanent residence in Canada afteryou were determined to be a protected person?YesNoIf yes, on whatdate did youapply?Month16. Has your or a family member's status in Canada as a protectedperson been revoked?YesNoDayYear10. Your mailing addressNo. andstreetApt.numberCityProvincePostalCodeThis form is made available by Citizenship and Immigration Canada and is not to be sold to applicants.IMM 5521 (06-2002) E(DISPONIBLE EN FRANÇAIS - IMM 5521 F)

PAGE 2 OF 217. Your family members who also require a Protected Person Status DocumentFor office use onlyclient ID numbersFamily nameFAMILY MEMBERFAMILY MEMBERFAMILY MEMBERGiven name(s)Other name(s)Date of birthDayMonthYearDayMonthYearDayMonthYearPlace of birthTown/CityCountryCountry of citizenshipCountry of lastpermanent residenceSexMaleFemaleMaleFemaleMaleFemaleHeightcmORftincmORftincm ORftinEye colourRelationshipMarital statusIs your family memberphysically present inCanada?Yes No Yes NoYesNoAuthority to release informationI give consent to release all information to the following person:Address of representativeAddress (No. & street)Apt./Suite no.Name of individualName of firmCity Province Postal codeDo you want all documents andcorrespondence mailed to this address?YesNoTelephoneArea Code( )Number-DeclarationThis declaration covers the information I have provided on this application form and the accompanying documents.• I declare that the information I have given is truthful, complete and correct.• I understand that any false statements or concealment of a material fact may be grounds for my prosecution or removal.• I understand all the foregoing statements, having asked for and obtained an explanation on every point that was not clear to me.• I will immediately inform the Citizenship and Immigration Canada if any of the information or the answers provided in my application formschange.SignatureDateDayMonthYearDeclaration of InterpreterI have faithfully and accurately interpreted inNamePlace signed(the language)Relationshipto applicantSignature ofinterpreterthe complete contents of this application.DateDayMonthYearTHE INFORMATION YOU PROVIDE ON THIS DOCUMENT IS COLLECTED UNDER THE AUTHORITY OF THE IMMIGRATION AND REFUGEE PROTECTION ACTTO ASSESS YOUR REQUEST FOR A PROTECTED PERSON STATUS DOCUMENT. THIS INFORMATION WILL BE STORED IN PERSONAL INFORMATIONBANK CIC PPU 066. IT IS PROTECTED AND YOU HAVE THE RIGHT OF ACCESS TO IT UNDER THE PRIVACY ACT.IMM 5521 (06-2002) E