Sworn Statement - Proof Of Residence Form Page 2
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1
2INSTRUCTIONS
IMPORTANT
A person who willingly misleads, declares or attests under oath a fact that he/she knows to be inaccurate is liable to be prosecuted
for perjury under the Criminal Code of Canada. The Régie de l'assurance maladie du Québec is entitled to verify the authenticity
of the declarations made in this statement.
Section to be completed by the landlord, the landlord's representative or the tenant whose name appears
on the lease, who is stating, under oath, the place of residence of the card applicant.
Enter :
• your first and last names, address and phone number
• the name of the person for whom the proof of residence must be provided
• the residential address of this person (if different from that of your own domicile)
Section to be completed before a commissioner for oaths.
Go to a commissioner's office for the signing of the sworn statement. Remember to take this form and an ID document with you.
Persons authorized to act in the capacity of commissioner for oaths include:
• commissioners for oaths appointed by the Ministère de la Justice (please refer to to find
the commissioner for oaths nearest you)
• certain employees at the reception desks of the Régie de l'assurance maladie du Québec
• lawyers and notaries duly registered with the Barreau du Québec or the Chambre des notaires du Québec and justices of the
peace, throughout Québec
• the mayor, councillor, clerk or secretary-treasurer of a municipality, within the territory of his/her municipality
• clerks of Québec courts and their assistants, within the judicial district where they are appointed
• the secretary general, assistant secretaries general and assistant secretaries of the National Assembly, throughout Québec
• agents in certain Services Québec offices (call to confirm before going there)
A fee may be required of the person having to provide proof of residence for the swearing-in.
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