Form 3 - Statutory Declaration Form
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2Form 3 - Statutory Declaration Form
Strictly Private and Confidential
THE DECLARATIONS MADE IN THIS FORM HAVE THE SAME FORCE AND EFFECT AS IF MADE UNDER OATH.
This form must be completed by the HCV Infected Class Member unless he or she is a minor, a mentally incompetent
adult or has died. If the HCV Infected Class Member is a minor, a mentally incompetent adult or has died, the Declarant of
this form must be a person who is/was sufficiently familiar with the HCV Infected Class Member to make the declarations
required to the best of his or her knowledge, information and belief. To satisfy this requirement in some cases, the person
making this Declaration may be someone other than the HCV Personal Representative.
If the HCV Infected Class Member for whom this form is submitted is/was a Primarily-Infected Class Member, complete
Section A, and Section D, lines 1, 2, 3, 4 and 5.
If the HCV Infected Class Member is/was a Secondarily-Infected Person, complete Section A, and Section D, line 2 about
the Primarily-Infected Class Member and Section B, and Section D, line 1 about the Secondarily-Infected Person.
If the Declarant is not the HCV Infected Class Member, also complete Section C.
The HCV Infected Class Member, the HCV Personal Representative or Other Knowledgeable Person must sign this
form (line 6) in the presence of a Commissioner of Oaths. A Commissioner of Oaths is a person authorized to take
affidavits, a justice of the peace or a notary public for the province, territory or jurisdiction where the Declaration
is made.
Section A - Primarily - Infected Class Member
Last Name _______________________ First Name ______________________ Middle Initial ____________________
Home Address ___________________________________________________________________________________
City _________________________________________ Province/Territory ___________ Postal Code _____________
Country ______________________________________ Date of Birth _______________________________________
(Month
Day
Year)
Province/Territorial Health Number ______________________________ Province/Territory of Health Plan __________
Home Phone ( _______) ___________ - __________________ Work Phone ( _______ ) ___________ - __________
Section B - Secondarily - Infected Person
Last Name _______________________ First Name ______________________ Middle Initial ____________________
Home Address ___________________________________________________________________________________
City _________________________________________ Province/Territory ___________ Postal Code _____________
Country ______________________________________ Date of Birth _______________________________________
(Month
Day
Year)
Province/Territorial Health Number ______________________________ Province/Territory of Health Plan __________
Home Phone ( _______) ___________ - __________________ Work Phone ( _______ ) ___________ - __________
Section C - Declarant
If the Declarant is the HCV Infected Class Member, skip this question and go to Section D – Declarations.
Last Name _______________________ First Name ______________________ Middle Initial ____________________
Home Address ___________________________________________________________________________________
City _________________________________________ Province/Territory ___________________________________
Postal Code _____________________________Country _________________________________________________
Home Phone ( _______) ___________ - __________________ Work Phone ( _______ ) ___________ - __________
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