PROTECTED WHEN COMPLETED - B

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CONFIRMATION OF CANADIAN CITIZENSHIP PART 1

OF THE ADOPTIVE PARENT(S)
APPLICATION FOR CANADIAN CITIZENSHIP FOR A PERSON ADOPTED BY A CANADIAN CITIZEN

FOR OFFICIAL USE ONLY

Receipt no. File no.
Return original document(s) ►
First generation
Client ID Certificate no. Citizenship confirmed ► No Yes
limitation ►
Application ID Mission
Signature

Place (city/town) Date (YYYY-MM-DD)

Before you start completing this form, make enough photocopies for your needs. You can also print all or part of this form from our website at www.cic.gc.ca.

If there is not enough space to provide all the necessary information, attach to this form a separate sheet of paper with further details. Print your name at the top of each
additional sheet and indicate the form's title and the number of the question you are answering.

BEFORE YOU START, READ THE INSTRUCTION GUIDE

TYPE or PRINT in black or blue ink

1
I want service in English French Check ✔ one

2 APPLICANT'S INFORMATION
A Who is applying on behalf of the adopted person for Canadian citizenship?

The adoptive parent The adopted person (if aged 18 years or older) The legal guardian

Note: Adopted persons 18 years of age or older must fill in and sign their own application.
B Name and addresses of the person applying for the adopted person's Canadian citizenship
Last name (surname/family name) Given name(s)

C Residential address
No. and street Apt./unit

City/Town Province/Territory Postal code Country

D Mailing address (if different from section 2C)

No. and street Apt./unit

City/Town Province/Territory Postal code Country

E The address is also required in the local language where the applicant is living (for example: Arabic, Cyrillic, Chinese, Korean, Japanese characters or Chinese commercial/
telegraphic code). Only if applicable.

F Country code Area code and no. Country code Area code and no.
Home telephone no. ► Cellular telephone no. ►
Country code Area code and no. Country code Area code and no.
Business telephone no. ► Facsimile no. ►

E-mail address ►
By indicating your e-mail address, you are hereby authorizing IRCC to transmit all correspondence, including your file and personal information to this specific e-mail address.

This form is made available by Immigration, Refugees and Citizenship Canada and is not to be sold to applicants.
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(DISPONIBLE EN FRANÇAIS - CIT 0010 F)
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3 DETAILS OF ADOPTIVE PARENT(S)
ADOPTIVE PARENT
A Last name (surname/family name) Given name(s)

Other name(s) used (include birth name, maiden, previous married name(s), aliases and nicknames) Country of birth Date of birth (YYYY-MM-DD)

B Canadian citizenship information

Is the adoptive parent a Canadian citizen? No Yes ► If yes, how did the adoptive parent obtain Canadian citizenship?
Write details (for example: by birth, by naturalization, by birth from a Canadian parent outside Canada, etc.)

At the time of the adopted person's adoption, was the adoptive parent employed outside Canada in or with the Canadian Armed Forces, the federal public administration or the
public service of a province or territory other than as a locally engaged person?
No Yes ► If yes, provide details of their employment
C Was the adoptive parent issued a Canadian citizenship certificate in the past?
No Yes If yes, certificate number: ►
Name that appears on the certificate:
Last name (surname/family name) Given name(s)

D Presence outside Canada before 1977

Did the adoptive parent reside outside Canada for No Yes ► If yes, write details. From
(YYYY-MM)
To
(YYYY-MM) Destination (country)
more than one (1) year before 1977?

E Dual citizenship
Is the or was the adoptive parent a citizen of a country or countries other than Canada? No Yes ► If yes, write details.
Attach a separate page if needed.
Country Date citizenship was obtained (YYYY-MM-DD) How was citizenship obtained?

F Adoptive parent's parents

1) If the adoptive parent was born outside Canada, was one of his/her parents No Yes
a Canadian citizen at the time of his/her birth?
2) If the adoptive parent was born outside Canada, was one of his/her parents employed
outside Canada as a Crown servant (in or with the Canadian Armed Forces, the federal
public administration or the public service of a province or territory other than as a locally
No Yes
engaged person) at the time of his/her birth or adoption?

► If your answer is yes to either question, give details:

ADOPTIVE PARENT'S PARENT ADOPTIVE PARENT'S PARENT

Surname/Last name

Other names used (name at birth,

maiden name)

Given name(s)

YYYY-MM-DD YYYY-MM-DD
Country and date of birth

Details on how the adoptive parent's

parent obtained Canadian citizenship

Details on Crown service

G Employment details of the parents of the adoptive parent

Has one of the parents of the adoptive parent been employed by a foreign government or
international agency?
No Yes ► If yes, write details.

Attach a separate page if needed.

Name of the employer Employment start date (YYYY-MM-DD)

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3 DETAILS OF ADOPTIVE PARENT(S) (continued)
OTHER ADOPTIVE PARENT
A Last name (surname/family name) Given name(s)

Other name(s) used (include birth name, maiden, previous married name(s), aliases and nicknames) Country of birth Date of birth (YYYY-MM-DD)

B Canadian citizenship information

Is the other adoptive parent a Canadian citizen? No Yes ► If yes, how did the adoptive parent obtain Canadian citizenship?
Write details (for example: by birth, by naturalization, by birth from a Canadian parent outside Canada, etc.)

At the time of the adopted person's adoption, was the adoptive parent employed outside Canada in or with the Canadian Armed Forces, the federal public administration or the
public service of a province or territory other than as a locally engaged person?
No Yes ► If yes, provide details of their employment
C Was the adoptive parent issued a Canadian citizenship certificate in the past?
No Yes If yes, certificate number: ►
Name that appears on the certificate:
Last name (surname/family name) Given name(s)

D Presence outside Canada before 1977

Did the adoptive parent reside outside Canada for No Yes ► If yes, write details. From
(YYYY-MM)
To
(YYYY-MM) Destination (country)
more than one (1) year before 1977?

E Dual citizenship
Is the or was the adoptive parent a citizen of a country or countries other than Canada? No Yes ► If yes, write details.
Attach a separate page if needed.
Country Date citizenship was obtained (YYYY-MM-DD) How was citizenship obtained?

F Other adoptive parent's parents

1) If the other adoptive parent was born outside Canada, was one of his/her parents No Yes
a Canadian citizen at the time of his/her birth?
2) If the other adoptive parent was born outside Canada, was one of his/her parents
employed outside Canada as a Crown servant (in or with the Canadian Armed Forces,
the federal public administration or the public service of a province or territory other than
No Yes
as a locally engaged person) at the time of his/her birth or adoption?

► If your answer is yes to either question, give details:

ADOPTIVE PARENT'S PARENT ADOPTIVE PARENT'S PARENT

Surname/Last name

Other names used (name at birth,

maiden name)

Given name(s)

YYYY-MM-DD YYYY-MM-DD
Country and date of birth

Details on how the adoptive parent's

parent obtained Canadian citizenship

Details on Crown service

G Employment details of the parents of the adoptive parent

Has one of the parents of the adoptive parent been employed by a foreign government or
international agency?
No Yes ► If yes, write details.

Attach a separate page if needed.

Name of the employer Employment start date (YYYY-MM-DD)

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4 ADOPTION DETAILS
A
Has the adoption been completed? ► No Yes

Place (city/town) Region/Province Country

► If no, • Where will it be completed?

(YYYY-MM-DD)
► If yes, • When was it completed?

• Which country issued the Place (city/town) Region/Province Country

adoption order?

• Age of adopted person

at time of adoption?

Is the adopted person a relative

B
of the adoptive parent(s)?
No Yes ► If yes, what is the relationship?

C Where is the adopted person Place (city/town) Region/Province Country

currently living (if known)? ►
If the adopted person is currently living outside Canada, will the adopted person come to Canada
D
to live as soon as Canadian citizenship is granted? ► No Yes

If yes, write the name of the province or territory in which the adopted person will be living Province/Territory
► after their arrival in Canada.

5 PERSONAL DETAILS OF THE ADOPTED PERSON

A Do you know the personal details of
the adopted person? No ► If no, go to section 6. Yes I am the adopted person

B Last name (surname/family name) at birth of the adopted person Given name(s) at birth of the adopted person

5 PERSONAL DETAILS OF THE ADOPTED PERSON (continued)

C Date of
(YYYY-MM-DD) Place of birth (city/town) Country of birth Country or countries of current citizenship
birth
D
Sex ► Female Male

E Do you know where the adopted

person currently lives?
No Yes I am the adopted person (skip this section) ► If yes, include the address
No. and street Apt./Unit City/Town Province/Territory Postal code Country

Name of the contact person/organization

F Have you previously submitted a sponsorship or

permanent residence application for this person?
No Yes ► If yes, write the approximate date (YYYY-MM)

6 APPOINTMENT OF A REPRESENTATIVE
Are you appointing an individual, firm or organization
No Yes
as your representative?

► If yes, the Use of a Representative form (IMM 5476) must be completed and included with your application.

Name of individual who assisted in completing this application form Name of firm, organization

Address

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7 DECLARATION AND SIGNATURE

I have read and understood the contents of this form. I declare that the information that I have provided in this form is true, complete and accurate, and that the photographs
enclosed are a true likeness of me. I understand that if I, or someone on my behalf, made a false representation, commit fraud or conceal any material circumstances relevant to the
adopted person's application, the application could be denied or the adopted person could lose his or her Canadian citizenship. I understand that by providing false or misleading
information, making a false declaration or failing to declare all information material to the adopted person's application, I could be charged with an offence under the Citizenship Act,
or the Criminal Code.

Signature of adoptive parent/legal guardian or the adopted person (if 18 years of age or older)

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

City
► (YYYY-MM-DD)
Date

IMPORTANT NOTE:
The application must be signed and dated before it is mailed. If your application is not signed and dated, it will be returned to you. You must make sure that all
information you have entered is accurate and is up-to-date. Remember to make sure that you are eligible to apply on the day before you SIGN this application.

REMEMBER:
You must submit one application form for each adopted person. If you are sending more than one application, send all of them together in one envelope. The
applications will be processed together.

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 subsection 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 IRCC offices and at any Canadian public library.

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