Solemn declaration for estate representative

Large-print version of official source

Solemn declaration for estate representative (PDF 122.25 KB)

Complete this form if you need to notify us that an appellant has passed away.

1 – Contact information for the estate representative

First name

Last name

Tribunal file number

Home / business address (No., Street, R.R.)

Apt. / unit

City / town

Province / territory

Postal code

Country

Phone number (with area code)

Email address (optional)

2 – Solemn declaration

I,

, solemnly declare that:

1. The Deceased Appellant,

passed away on

2. I am applying to start or continue the Deceased Appellant’s appeal at the Social Security Tribunal on behalf of the estate.

3. Please check the box that applies to you:

I am authorized to administer the Deceased Appellant’s estate.

If there is any other person who is or may be authorized to administer the Deceased Appellant’s estate, I have obtained their consent to continue the appeal before the Tribunal on behalf of the estate. I have attached a copy of one of the following documents:

a copy of the Deceased Appellant’s will, appointing me as the executor or liquidator
a copy of the court order appointing me as the administrator, estate trustee or liquidator
a copy of the designation or agreement naming me as the liquidator

I do not have any document that confirms my authority to administer the Deceased Appellant’s estate.

I am not aware that the Deceased Appellant had a will or that there is anyone who is authorized to administer the Deceased Appellant’s estate.

My relationship to the Deceased Appellant is:

3 – Signature of declarant

I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same legal force and effect as if made under oath.

Signature of declarant

Year - Month - Day