Public Works and Government Services Canada
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Statutory Declaration

Canada
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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)

in the matter of

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)

that, up to the date of the attached Progress Claim, the contractor has complied with all its lawful obligations in respect of the Labour Conditions, discharged all its lawful obligations to workmen in respect of the work contracted for and has discharged all its lawful obligations to its subcontractors and suppliers except for the amounts owing which total $ if nil, state nil. A detailed explanatory statement of the amounts owing, including any amounts in dispute must be attached as part of this Statutory Declaration); or

that, up to the effective date of the certificate of substantial completion, the contractor has complied with all its lawful obligations in respect of the Labour Conditions, fully discharged all its lawful obligations to workmen, its subcontractors and suppliers in respect of the work contracted for and, in the case of a non-resident contractor, to the provincial tax authority respecting the payment of all applicable provincial taxes arising from or related to the performance of the work under the Contract, except for the amounts owing which total $ (if nil, state nil. A detailed explanatory statement of the amounts owing, including any amounts in dispute must be attached as part of this Statutory Declaration); or

that, up to the date of the certificate of completion, the contractor has complied with all its lawful obligations in respect of the Labour Conditions, fully discharged all its lawful obligations to workmen, its subcontractors and suppliers in respect of the work contracted for and discharged and satisfied all lawful claims against it that arose out of the performance of this Contract except for the amounts owing which total $ (if nil, state nil. A detailed explanatory statement of the amounts owing, including any amounts in dispute must be attached as part of this Statutory Declaration).

(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.