PROTECTED WHEN COMPLETED - B

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DECLARATION CONCERNING A LOST, STOLEN, INACCESSIBLE, DAMAGED OR FOUND

CANADIAN TRAVEL DOCUMENT
WARNING to applicant—Any false or misleading statement on this form or relating to any document in support of your Canadian travel document application,
including concealment of any material fact, may lead to refusal to issue or revocation of a Canadian travel document and be grounds for criminal prosecution.
TYPE OR PRINT IN CAPITAL LETTERS using black or dark blue ink.
1 PERSONAL INFORMATION AS INDICATED ON MOST RECENT CANADIAN TRAVEL DOCUMENT
The Canadian travel document was issued in: My name Child's name

Surname (last name) Given name(s)

Date of birth Place of birth

(YYYY-MM-DD) City Country Prov./Ter./State (if applicable)

Document number (if known) Date of issue (if known) Place of issue (if known)

(YYYY-MM-DD) City Country

Signature of applicant Date Signed at

(YYYY-MM-DD) City Country

Is the Canadian travel document being submitted with your declaration? No 4Continue to section 2 Yes 4Continue to section 3
2 INFORMATION CONCERNING A VALID CANADIAN TRAVEL DOCUMENT NO LONGER IN MY POSSESSION
Note: Incomplete descriptions may result in the delay or refusal of your application. If insufficient space, attach a separate signed and dated sheet.

The Canadian travel document listed in section 1 is no longer in my possession because (please provide a detailed explanation as to why you
are not submitting the Canadian travel document and what has happened to it)

I have made the following efforts to recover this Canadian travel document (please explain)

Date this Canadian travel document was lost, stolen or became inaccessible (YYYY-MM-DD)

This Canadian travel document was last used on Location

(YYYY-MM-DD) City Country

Was a police report filed?

Yes Date of report (YYYY-MM-DD) Report number Name of police service

No Please provide the reason for not filing a police report

Were any other provincial or federal identification documents lost or stolen? Yes No

PPTC 203 (06-2019) E (DISPONIBLE EN FRANÇAIS - PPTC 203 F)

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3 INFORMATION CONCERNING A DAMAGED OR FOUND CANADIAN TRAVEL DOCUMENT

Note: If insufficient space, attach a separate signed and dated sheet.

Detailed circumstance of how the Canadian travel document was damaged or found

Explain why you are applying for a replacement Canadian travel document

Date Canadian travel document was damaged or found Location

(YYYY-MM-DD) City Country

Reminder: A Canadian travel document application form must also be completed if a replacement Canadian travel document is required. Please note that the Canadian travel
document specified in this form cannot be used for the simplified renewal process.

4 DECLARATION OF APPLICANT
Surname (last name)

Given name(s) Daytime telephone number Date of birth (YYYY-MM-DD)

DECLARATION—I solemnly declare that, to my knowledge, the statements made in this declaration are true. Should I ever regain possession of the Canadian travel document
reported in section 1, I will return it immediately to the Passport Program or if abroad to the nearest Government of Canada office. I acknowledge that a Canadian travel document
once reported lost, stolen, inaccessible, damaged or found is no longer valid and is NOT to be used for any travel. I understand multiple occurrences of Lost/Stolen or
Damaged Canadian travel documents may result in either the refusal to issue a replacement Canadian travel document, or if approved, a severely limited validity of the replacement
Canadian travel document. I also acknowledge that additional requirements may apply, such as demonstrating the need to be issued a Canadian travel document. I declare that I
have read and understood the WARNING to applicant at the top of page 1.

Signature of applicant Date Signed at

(YYYY-MM-DD) City Country

FOR OFFICE USE ONLY

Based on the information provided by the applicant on this form, the Canadian travel document has been identified as
Lost Stolen Damaged Mutilated Inaccessible Found

Name of officer who reviewed the above information (stamp recommended) Date (YYYY-MM-DD)

Document number Date of issue Place of issue

(YYYY-MM-DD) City Country

To obtain the most recent version of this form, visit our website at Canada.ca/passport.

PRIVACY NOTICE STATEMENT — Personal information provided on this form is collected by Immigration, Refugees, and Citizenship Canada (IRCC) under the authority of the
Canadian Passport Order. The personal information provided will be used for the purpose of processing applications, determining entitlement to passport services and administering
passport services The personal information provided may be disclosed to other federal government institutions, provincial/territorial governments, foreign governments, investigative
bodies and/or law enforcement for the purpose of validating identity, determining current and ongoing entitlement to passport services and administering or enforcing any law or
carrying out a lawful investigation.

Personal information may also be used for purposes including research, statistics, quality assurance, program and policy evaluation, internal audit, compliance, risk management,
strategy development and reporting. Failure to complete the form in full may result in a delay or the application not being processed. The Privacy Act gives individuals the right of
access to, protection, and correction of their personal information. If you are not satisfied with the manner in which IRCC handles your personal information, you may exercise your
right to file a complaint to the Office of the Privacy Commissioner of Canada. The collection, use, disclosure and retention of your personal information is further described in IRCC’s
Personal Information Bank – IRCC PPU 081 and IRCC PPU 082.
PPTC 203 (06-2019) E