(Subsection 4(1) and section 5)
|NOTE: To the best of your knowledge, please indicate the following:|
|Name of the Department:|
|Name of the Program:|
|Estimate of amount claimed:|
|Note:||All deletions or alterations are to be initialled by the applicant and the witnesses.|
Province of ________________________
IN THE MATTER OF THE ESTATE OF:
(Full name of deceased)
1. I,(Full name of applicant), age ______, of(Address)
in(City, town or village) in the Province of(Name of province) Postal Code______
make an application in accordance with section 3 of the Payments to Estates Regulations, 1996.
2. That I am the(Relationship) of the late(Full name of deceased) who died at(City, town or village) in the Province of (Name of province) on the(Date) day of(Month), (Year) a copy of whose death certificate is attached to this application, and who died: (check one only) without a will with a will, a copy is attached.
(Note: if the will is a holograph, provide proof that it has been probated.)
3. That at the time of death, the deceased had his/her permanent residence in(City, town or village), (Province).
4. That I am (check one only)
[ ] the only person entitled to succeed to the assets of the deceased
[ ] one of the persons entitled to succeed to the assets of the deceased, and all other persons so entitled are listed and have signed the release in the form of Schedule II to the Payments to Estates Regulations, 1996.
5. That the information provided in this application is correct.
6. That I agree to indemnify and save harmless Her Majesty in right of Canada from any loss or damage that may be incurred as a consequence of making the payment to me.
7. That I agree to return any overpayment or erroneous payment, which constitutes a debt due to the Her Majesty in right of Canada.
(Applicant - signature) (Witness 1 - signature) (Witness 1 - signature).
(Witness 1 - Name in capital letters)(Witness 2 - Name in capital letters)
(City, town or village), in the Province of (Name of province)
(Date) day of (Month), (Year).
Note: The witnesses must have no interest in the estate of the deceased and must not be related to the applicant.
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