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CIT 0010 (02-2016) E

PROTECTED WHEN COMPLETED - B

(DISPONIBLE EN FRANÇAIS - CIT 0010 F)

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

PART 1

This form is made available by Immigration, Refugees and Citizenship Canada and is not to be sold to applicants.

FOR OFFICIAL USE ONLY

Receipt no. File no.Return original document(s) ►

Certificate no. Citizenship confirmed ► No Yes First generation limitation ►Client ID

MissionSignature

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

Application ID

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 FrenchEnglish Check one

2 APPLICANT'S INFORMATIONA 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.

Name and addresses of the person applying for the adopted person's Canadian citizenshipBLast name (surname/family name) Given name(s)

C Residential addressNo. 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.

FHome telephone no. ►

Country code Area code and no.Cellular telephone no. ►

Country code Area code and no.

Business telephone no. ►

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.

Country code Area code and no.Facsimile no. ►

Country code Area code and no.

E-mail address ►

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CIT 0010 (02-2016) E

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)

Canadian citizenship informationB

Is the adoptive parent a Canadian citizen? YesNo ► 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 employmentC 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 more than one (1) year before 1977?

No Yes ► If yes, write details. From (YYYY-MM)

To (YYYY-MM) Destination (country)

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.

Country Date citizenship was obtained (YYYY-MM-DD) How was citizenship obtained?

Attach a separate page if needed.

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

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

Attach a separate page if needed.

F Adoptive parent's parents 1) If the adoptive parent was born outside Canada, was one of his/her parents

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 engaged person) at the time of his/her birth or adoption?

No Yes

ADOPTIVE PARENT'S PARENT ADOPTIVE PARENT'S PARENT

Surname/Last name

Other names used (name at birth, maiden name)

Given name(s)

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

Details on how the adoptive parent's parent obtained Canadian citizenship

Details on Crown service

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

No Yes

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CIT 0010 (02-2016) E

3 DETAILS OF ADOPTIVE PARENT(S) (continued)

D Presence outside Canada before 1977

Did the adoptive parent reside outside Canada for more than one (1) year before 1977?

No Yes ► If yes, write details. From (YYYY-MM)

To (YYYY-MM) Destination (country)

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.

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

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 as a locally engaged person) at the time of his/her birth or adoption?

No Yes

ADOPTIVE PARENT'S PARENT ADOPTIVE PARENT'S PARENT

Surname/Last name

Other names used (name at birth, maiden name)

Given name(s)

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

Details on how the adoptive parent's parent obtained Canadian citizenship

Details on Crown service

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

No Yes

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)

Attach a separate page if needed.

OTHER ADOPTIVE PARENTA 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

Employment details of the parents of the adoptive parentGHas one of the parents of the adoptive parent been employed by a foreign government or international agency? YesNo ► If yes, write details.

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

Attach a separate page if needed.

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CIT 0010 (02-2016) E

APPOINTMENT OF A REPRESENTATIVE6

No YesAre you appointing an individual, firm or organization 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

Do you know where the adopted person currently lives?

ENo 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

Have you previously submitted a sponsorship or permanent residence application for this person?

FNo Yes ► If yes, write the approximate date (YYYY-MM)

PERSONAL DETAILS OF THE ADOPTED PERSON (continued)5

Date of birth

C (YYYY-MM-DD) Country or countries of current citizenshipCountry of birthPlace of birth (city/town)

Sex ►D Female Male

ADOPTION DETAILS4

Has the adoption been completed? ►A No Yes

► If no, • Where will it be completed?Place (city/town) Region/Province Country

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

• Which country issued the adoption order?

Place (city/town) Region/Province Country

• Age of adopted person at time of adoption?

Is the adopted person a relative of the adoptive parent(s)?

B No Yes ► If yes, what is the relationship?

Where is the adopted person currently living (if known)?

C

If the adopted person is currently living outside Canada, will the adopted person come to Canada to live as soon as Canadian citizenship is granted?

D

►CountryRegion/ProvincePlace (city/town)

► No Yes

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

Province/Territory

PERSONAL DETAILS OF THE ADOPTED PERSON5Do you know the personal details of the adopted person?

ANo ► If no, go to section 6. Yes I am the adopted person

Given name(s) at birth of the adopted personLast name (surname/family name) at birth of the adopted personB

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CIT 0010 (02-2016) E

DECLARATION AND SIGNATURE7

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

Date

(YYYY-MM-DD)

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.