Omar Gomis

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CONFIRMATION OF ELIGIBILITY FOR GRATIS REPLACEMENT OF A VALID

PASSPORT OR TRAVEL DOCUMENT - REFLECTION OF RECLAIMED INDIGENOUS
NAME - CHILD - UNDER 16 YEARS OF AGE
This form is for applicants seeking to replace a child’s valid Canadian passport or travel document in their possession with one that reflects their reclaimed
Indigenous name. The passport or travel document being replaced must have been issued for five (5) years, it cannot be damaged or declared as lost or
stolen and it must have at least six (6) months of validity remaining.
The gratis replacement will be issued with the same expiry date as the passport or travel document being replaced. Only the fees for the replacement
issuance of a passport or travel document will be waived. The cost for replacement of passport photos can be reimbursed with a proof of purchase to support
the refund request. Additional service fees (e.g. urgent, express, pick-up) will not be waived.
SECTION A: CONFIRMATION OF ELIGIBILITY

The child is: (check the boxes that apply)
A direct descendant of a residential school survivor (e.g. child, grandchild, great-grandchild);
An Indigenous person.
I am submitting this form to support my request for: (check the box that applies)
A gratis replacement of a valid passport (regular, special or diplomatic);
A gratis replacement of a valid travel document (certificate of identity or refugee travel document) – In Canada only.
SECTION B – CHILD’S PERSONAL INFORMATION

Surname (last name) to appear in the new passport or travel document
Given name(s) to appear in the new passport or travel document
Date of birth (YYYY/MM/DD)
Current Passport or Travel Document Details
Surname (last name) Given name (s)
Passport or Travel Document number. (Please include this passport or travel document with your application. Date of issue (YYYY/MM/DD) Date of expiry (YYYY/MM/DD)
It will not be returned to you after cancellation.)
SECTION C - INFORMATION ON PARENT(S) OR LEGAL GUARDIAN(S)

Is the child currently the subject of an adoption process or partially or fully in the care of a provincial or territorial family services in Canada?
No
Yes, include all documents
Since the previous application, have there been any changes pertaining to custody of, mobility of or access to the child?
No
Yes, include all documents
PPTC 658 (09-2021) E (DISPONIBLE EN FRANÇAIS - PPTC 658 F)

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Relationship between the applicant (parent or legal guardian) and the other parent(s) or legal guardian(s):
Applicant parent or legal guardian Other parent or legal guardian

Current surname (last name) Current surname (last name)
Given name(s) Given name(s)
All former surname(s) (if different from above) All former surname(s) (if different from above)
Date of birth (YYYY-MM-DD) Country of Birth Date of birth (YYYY-MM-DD) Country of Birth
Telephone (daytime) Telephone (Other) Telephone (daytime) Telephone (Other)
Email address Email address
Current home address Current home address
Signature Date (YYYY/MM/DD) Signature Date (YYYY/MM/DD)

Applicant’s mailing address (Number, Street, Apt, City, Prov./Terr./State Postal/ZIP code)
SECTION D - ACKNOWLEDGEMENT
I acknowledge that the replacement passport or travel document may not be universally accepted for entry or exit by border authorities of another country if the child’s personal
information is different from what is found on other identification documents.
SECTION E - APPLICANT SIGNATURE

I declare that the information provided on this form is true. I declare that I have read and understood the content of this form.
Name of applicant parent or legal guardian
Signature of applicant parent or legal guardian Signed at Date (YYYY/MM/DD)
SECTION F - DOCUMENTS TO INCLUDE WITH YOUR REQUEST:

The child’s valid passport or travel document
Child’s passport application form (if applying from outside of Canada). There is no need to provide a guarantor
Proof of Canadian citizenship (please provide the document(s) you have):
- Original proof of Canadian citizenship or copy of Immigration Status Document in the reclaimed name, or
- Original proof of Canadian citizenship in the previous name and the original or copy of a legal name change document, court order, or adoption order showing the previous
name and the reclaimed name
Two identical passport photos taken within the last six (6) months with proof of purchase. The photos do not need to be signed by a guarantor
Acceptable proof of parentage
Documents (including any divorce judgment) that refer to the custody of, mobility of, or access to the child, if different from previous application
Adoption or family service documents, if applicable.
PPTC 658 (09-2021) E

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PROTECTED WHEN COMPLETED - B

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CONFIRMATION OF ELIGIBILITY FOR GRATIS REPLACEMENT OF A VALID

SECTION A: CONFIRMATION OF ELIGIBILITY

A direct descendant of a residential school survivor (e.g. child, grandchild, great-grandchild);

A gratis replacement of a valid passport (regular, special or diplomatic);

SECTION B – CHILD’S PERSONAL INFORMATION

Given name(s) to appear in the new passport or travel document

Date of birth (YYYY/MM/DD)

Current Passport or Travel Document Details

Surname (last name) Given name (s)

SECTION C - INFORMATION ON PARENT(S) OR LEGAL GUARDIAN(S)

Yes, include all documents

Yes, include all documents

PPTC 658 (09-2021) E (DISPONIBLE EN FRANÇAIS - PPTC 658 F)

Applicant parent or legal guardian Other parent or legal guardian

Given name(s) Given name(s)

Telephone (daytime) Telephone (Other) Telephone (daytime) Telephone (Other)

Email address Email address

Current home address Current home address

Signature Date (YYYY/MM/DD) Signature Date (YYYY/MM/DD)

SECTION E - APPLICANT SIGNATURE

Name of applicant parent or legal guardian

Signature of applicant parent or legal guardian Signed at Date (YYYY/MM/DD)

SECTION F - DOCUMENTS TO INCLUDE WITH YOUR REQUEST:

Proof of Canadian citizenship (please provide the document(s) you have):

Acceptable proof of parentage

Adoption or family service documents, if applicable.

PPTC 658 (09-2021) E

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