PAGE 2 OF 3
PART B - INFORMATION TO BE AMENDED (continued)
2
3
Surname(s) (Family name)
Given name(s)
4
5 Place of birth (City, state/province)
Date of birth
YYYY-MM-DD
6 Country of birth
7 Citizenship
8 Sex
9 Marital status
Male
Female
Never married
Married
Common-law partner
Widowed
Divorced
Separated
12
Other change (Provide a description in PART C, section 2 below)
10
11
Date of original entry
Date permanent residence or temporary
(
residence was granted
YYYY-MM-DD)
(YYYY-MM-DD)
PART C
1
If you are applying for an amendment to your IMM 1000, IMM 5292 or IMM 5688 and you are not a Canadian citizen, have you, since your admission to Canada
as a permanent resident, been convicted of a crime or offence in Canada or elsewhere?
No
Yes
If yes, attach copies of the relevant court documents.
2
Reasons for requesting the amendment(s). (Attach another sheet if you need more space.)
STATEMENT
I certify that the statements made on this application document are true and correct. I understand that the approval of my request to amend my date of birth may affect my
eligibility for benefit and services from other government institutions as that term is defined in the Privacy Act and may also result in the recovery from me by other
government institutions of payments or benefits made to me under income support programs for which I was not eligible at the time the payments or benefits were paid.
Date
Signature
YYYY-MM-DD
The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act for the purposes of verifying your status in
Canada. It will be stored in Personal Information Banks (PPU 053 entitled Permanent Resident Data System) CIC. Information may be systematically validated by other
Canadian government institutions under the terms of an agreement or arrangement for the purposes of validating status and identity to administer their programs. In
accordance with the Privacy Act and the Access to Information Act, individuals have a right to access, correction and protection of their personal information. Details on
these matters are available at the CIC website ( ).
IMM 1436 (10-2015) E
1
2
3
