Statutory Declaration

Canada

Province or Territory of ___.

in the matter of a contract bearing no.___. and dated the ___ day of ____ between her majesty the queen in right of Canada, and (Insert full name of Contractor), hereinafter referred to as the Contractor, for (Description and location of work), and in the matter of (indicate by checkmark - in applicable box)

[ ] a progress claim covering work done thereunder up to the ___ day of ___.

[ ] the certificate of substantial completion relating thereto.

[ ] the certificate of completion of the work thereunder.

to wit:

I,(Print or type name of Declarant), of (Declarant's address) do solemnly declare:

(1)

that I am (Print or type Declarant's title or position with the Contractor or state that Declarant is the Contractor) 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).

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.

declared before me at ___ this day of , ___

(Signature of person before whom the Declaration is made)

(Print name of person before whom the Declaration is made)

A Notary Public, Commissioner, etc. (Please state authority for receiving Declarations-Notaries to affix Notarial Seal)

(Signature of Declarant)

notice

If this Declaration is not complete in every detail, it will be returned for completion and payment will be delayed. Sections 134 and 361 of the Criminal Code of Canada which deal with offences relating to affidavits are hereby brought to the attention of the Declarant.