11 Date of issue YYYY-MM-DD. If you are married, is your spouse a Canadian citizen or permanent resident?

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1 Citizenship Immigration Canada Citoyenneté et Immigration Canada PROTECTED WHEN COMPLETED - B PAGE 1 OF 4 VERIFICATION OF STATUS (VOS) REPLACEMENT OF AN IMMIGRATION DOCUMENT (To be completed returned with the application checklist) PART A - PERSONAL DETAILS 2 on entry 3 on entry 1 Client ID number/uci 4 Current surname (if different from name on entry) 5 Current given name (if different from name on entry) 6 Sex Male Female 7 10 Passport number Indicate if: On entry 13 Marital status on entry Never married Married 8 Place of birth (City, state/province country) 9 Citizenship Current 11 Date of issue If you are married, is your spouse a Canadian citizen or permanent resident? 12 Expiry date Widowed Separated Divorced Common-law partner 14 Language of correspondence English French 15 Current mailing address P.O. box Apt./Unit Street no. Street name City/Town Country Province/State Postal code District 16 Residential address Same as mailing address? Apt./Unit Street no. Street name City/Town Country Province/State Postal code District Telephone no. Canada/US Other Alternate Telephone no. Canada/US Other Type Country Code. Ext. Type Country Code. Ext. 19 address: (Indicating an address will authorize all correspondence, including file personal information, to be sent to the address you specify.) 20 Immigration document Date of Issue 21 Canadian port of entry - Place of issue PART B - DOCUMENTS REQUESTED 1 What type of request are you making? 2 Verification of Status Replacement of a valid temporary resident document Indicate for which of the following you need a replacement copy or a Verification of Status document. If you have more than one valid temporary resident document, indicate the document ID number or if unknown, the document issue expiry date of the requested document. Immigrant Visa Record of Ling - Confirmation of Permanent Residence Exclusion Order Departure Order Authorization to Return to Canada Permit to Come Into or Remain in Canada - Temporary Resident Permit Protected Person Work Permit ID.: () () Study Permit ID.: () () Visitor Record ID.: () () This form is made available by Citizenship Immigration Canada is not to be sold to applicants. (DISPONIBLE EN FRANÇAIS - IMM 5009 F)

2 PART B - DOCUMENTS REQUESTED (continued) 3 Was your original immigration document Lost Stolen Destroyed Other Provide details. If the document was a valid temporary resident document was lost or stolen, indicate the police report number. PAGE 2 OF 4 4 If you are requesting a Verification of Status of an Immigrant Visa Record of Ling/Confirmation of Permanent Residence have you applied for it before? If yes, when did you apply? 5 If you are applying for a Verification of Status of an Immigrant Visa Record of Ling/Confirmation of Permanent Residence 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? If yes, attach copies of the relevant court documents. 6 Are you a Canadian citizen? 7 List all names you have ever used. 8 Did you enter Canada as a Visitor Student Worker Permanent Resident Protected Person PART C - IF YOU ENTERED CANADA AS A PERMANENT RESIDENT PRI TO 1973, COMPLETE THE FOLLOWING SECTION 1 Provide the full names date of birth of the person(s) who accompanied you on arrival in Canada. (e.g., middle name, maiden name, English name or alias.) 2 Were either of your parents born Canadian citizens? 3 What are the names dates of birth of your parents?

3 PAGE 3 OF 4 4 What is/was the occupation of each of your parents? Mother's occupation Father's occupation 5 Had you or your parents ever been part of any military at the time you entered Canada? 6 Marital status at time you entered Canada Never married Married Common-law partner Widowed Divorced Separated DECLARATION I solemnly declare that the information I have provided is, to the best of my knowledge, complete accurate. I authorize the department of Citizenship Immigration Canada to verify the information I have provided. If I am requesting a replacement document should I ever regain possession of the original document, I promise to return it immediately to Citizenship Immigration Canada. Signature Date The information you provide on this form is collected under the authority of the Immigration Refugee Protection Act for the purposes of verifying your status in Canada. It will be stored in Personal Information Banks (entitled PPU 053 Permanent Resident Data System, PPU 054 Temporary Worker Records Case File, PPU 051 Foreign Student Records Case File) 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 identity to administer their programs. In accordance with the Privacy Act the Access to Information Act, individuals have a right to access, correction protection of their personal information. Details on these matters are available at the CIC website ( through the Citizenship Immigration Canada Call Centre.

4 PAGE 4 OF 4 DOCUMENT CHECKLIST VERIFICATION OF STATUS (VOS) REPLACEMENT OF AN IMMIGRATION DOCUMENT Ensure the following documents are included with your application. Check R each box once you enclose the item. Failure to provide a fully completed application or the necessary documents will result in the return of your application. Please make sure you complete this document include it with your application as the cover page. Submit photocopies of documents unless we ask for originals as they will not be returned to you. I HAVE ENCLOSED THE FOLLOWING ITEMS: Original application form Verification of Status (VoS) or Replacement of an Immigration Document (IMM 5009) completed signed. Photocopy of one piece of federal or provincial/territorial government issued photo identification if unavailable, photocopy of government issued photo identification from outside Canada. (See "Gather Documents" section in the Instruction guide for examples.) Photocopy of another form of identification issued by the federal or provincial/territorial government of Canada or if unavailable, a photocopy of government issued identification from outside Canada. (See "Gather Documents" section in the Instruction guide for examples.) Photocopy of court documents if you have been convicted of a crime since becoming a permanent resident (if you are not a Canadian citizen). Original Copy 2 of the fee payment form (IMM 5401) or online payment receipt. (See "Pay the Fees" section in the Instruction guide for the correct VoS fee) Original Use of a Representative (IMM 5476) form completed signed, if applicable. Proof of urgency, if applicable. REQUEST ON BEHALF OF A DECEASED PERSON Proof of death, Proof that you are the lawful executor or administrator of the estate. If the person is deceased less than 20 years, only the lawful executor or administrator of the estate may request the personal information. One piece of federal or provincial/territorial government issued photo identification of the lawful executor or administrator of the estate.