REPUBLIC OF THE PHILIPPINES ) PROVINCE OF PANGASINAN ) S. S.

MUNICIPALITY OF ASINGAN )

AFFIDAVIT
!, RAPHY ULEP CASTILLO, single, Filipino and a resident of Domanpot, Asingan, Pangasinan, Philippines, after having been duly sworn to in accordance with law, depose and say: That I personally know MYLENE MEDIANA POQUIZ, also of legal age, Filipino and presently residing at Toronto, Canada; That we are common-law-husband and wife since 2002 up to the present; That out of our relationship, we have one (1) minor child, HESHMON RALPH POQUIZ who was born on November 12, 2002 at Urdaneta City, Pangasinan, Philippines; That I am executing this affidavit freely and voluntarily to attest to the above-narrated facts and for ail legal intents and purposes the same may serve. FURTHER, AFFIANT SAYETH NONE. IN WITNESS WHEREOF, I have hereunto set my hand this 18th day of December, 2012 at Asingan, Pangasinan, Philippines.

RAPHY ULEP CASTILLO Affiant Driver's Lie No. A05-97-040022 Expires on September 28, 2014 At Land Transportation Office, Urdaneta City, Pangasinan, Philippines SUBSCRIBED AND SWORN to before me on the date and in the place first above written ATTY. ROSELLER A. VIRAY Notary Public Until December 31, 2012 PTR No. 6308915; 01-02-12 IBP No. 02008; Roil No. 35342

Doc. No. 8j/ Page No. /J Book No. 121 Series of 2012

| fr |

Citizenship and Immigration Canada

Immigration Canada

PROTECTED WHEN COMPLETED - A PAGE 1 OF 1

STATUTORY DECLARATION OF COMMON-LAW UNION

BEFORE YOU START, READ THE INSTRUCTION GUIDE. TYPE or PRINT In black Ink.

Mjaucma Country

Province/State/Territory

In the matter of an application made pursuant to the Immigration and Refugee Protection Act and Regulations and in the matter of common-law union, We.
(name of city. town, village) (name of country)

(name of declarant)

and
ff appfccabie) r

(name of declarant's partner) ( n e w of province, stale, territory)

Of

, county of , solemnly declare that we have cohabited in a conjugal relationship for

in the country of continuous year(s) from

Month

i I

Day

to I

I
Year

Day

Month

I-

My common-law partner and 1: J a) Have jointly signed a residential lease, mortgage or purchase agreement relating to a residence in which we both live. Yes ll
No

b) Jointly own property other than our residence. r-i

y

c) Have joint bank, trust, credit union or charge card accounts. Yes
No

d) Have declared our common-law union under the Canadian Income Tax Act. (T-1 "General Individual Income Tax Return") Yes
y

Yes

No

No

1 have life insurance on myself which names my common-law partner as beneficiary.

f~l No

l\y common-law partner has life insurance on ri him/herself which names me as beneficiary.

fT No

IT

f none of the above sections applies, what other documentary evidence do you have that would indicate your relationship as common-law partners?

jsj S O L E M N D E C L A R A T I O N

We make this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath. Name of declarant Name of declarant's partner Signature of declarant Signature of declarant's partner * _^

RAPHY ULEP CASTILLO

Declared before me at (City, Town, Village) county of p A g i n can Commissioner of Oaths (Name) Signature of Commissioner of Oaths , _ _ .

otary Public
a n g a s

i an,
n

Philippines in (country) oftheyeari? IOJ 1 I ?I

in the province/state/territory of this 1 8 t h day of December

-V

Information to be provided on the Statutory Declaration of Common-law Union is collected under the authority of the Immigration and Refugee Protection Act and is required to determine your eligibility or that of your partner with respect to an application for sponsorship, an application for permanent residence or an application for temporary residence. It may be used to enforce any provisions of the Act or its regulations and may be provided to provincial authorities pursuant to federal/provincial information exchange agreements. Information you provide on this form will be stored in Personal Information Banks CIC PPU 013 (Sponsors of immigrants), CIC PPU 015 (Immigration case files), CIC PPU 051 (Foreign students records and case file). CIC PPU 053 (Permanent resident data system), CIC PPU 054 (Foreign workers records and case file). It is protected and accessible under the provisions of the Pmacy Act and the Access to Information Act. Instructions for obtaining information are provided in InfoSource, a copy of which is located in all Citizenship and Immigration offices.

IMM 5409 (04-2009) E

(DISPONIBLE EN FRANCAIS - IMM 5409 F)

Canada