Public Works and Government Services Canada
Symbol of the Government of Canada

Statutory Declaration

Canada
.

in the matter of a
and dated the day of .
between her majesty the queen in right of Canada, and
,
hereinafter referred to as the Contractor,
for ,
and in the matter of

(indicate by checkmark - √ in applicable box)

covering work done thereunder up to the day of .

To wit:

I, , of do solemnly declare:

(1) that I am and as such have personal knowledge of the said Contract and of the facts and matters stated herein.

(2) (indicate by checkmark - √ in applicable box)

(3) that the were withheld by reason of legitimate dispute for which a statement is attached as part of this declaration, explaining in detail the reason(s) of the dispute(s) and identifying the party or parties from whom payment has been withheld.

And I 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, and by virtue of the canada evidence act.

this day of ,

________________________________________
(Signature of person before whom the Declaration is made)

________________________________________
(Signature of Declarant)

Notice

If this Declaration is not complete in every detail, it will be returned for completion and payment will be delayed. The making of a false or fraudulent declaration is a contravention of the Criminal Code of Canada, and could carry, upon conviction penalties including fines or imprisonment.