(DISPONIBLE EN FRANÇAIS - IMM 5492 F)

PROTECTED WHEN COMPLETED - B

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SPONSOR ASSESSMENT

IMM 5492 (03-2020) E

AName of sponsoring group (if applicable)

BName of sponsor - Family name Given name(s)

COther names used (include birth name, maiden, previous married names, aliases and nicknames)

D Are you 18 years of age or older? Yes No

E Are you a Canadian citizen, a Registered Indian or a permanent resident? Yes No

F Do you or your representatives reside in the expected community of resettlement? Yes No

G

Have you been convicted inside Canada of the offence of murder or an offence set out in Schedule I or II of the Corrections and Conditional Release Act? Refer to: (Schedule I: https://laws-lois.justice.gc.ca/eng/acts/C-44.6/section-sched108197.html Schedule II: https://laws-lois.justice.gc.ca/eng/acts/C-44.6/section-sched108325.html) Have you been convicted outside Canada of an offence that, if committed in Canada, would constitute one of the offences referred to above? (If you have received a pardon or final determination of acquittal, or if five years have elapsed since the completion of the sentence imposed, the conviction referred to above will not render you ineligible to sponsor refugees and you are not required to disclose the conviction details.)

Yes No

Yes No

If yes, provide conviction details:

Charge/Sentence Date (YYYY-MM-DD) Place

H Are you in default of any court-ordered support payment obligations? Yes No

I Are you currently detained in any penitentiary, jail, reformatory or prison? Yes No

J Have you been ordered to leave Canada? Yes No

K Are you subject of revocation proceedings under the Citizenship Act? Yes No

Disclosure of ineligibility information In the event that you are found to be ineligible to be a party to a sponsorship pursuant to subsection 156(1) of the Immigration and Refugee Protection Regulations (IRPR), do you authorize IRCC to disclose to the remaining parties that you cannot be a party to the sponsorship? The reason for your ineligibility finding will not be disclosed to anyone other than yourself.

L

Yes No

M – Signature I declare that the information given in this form and any attached documents is true, complete and accurate.

Date (YYYY-MM-DD)Signature

The information you provided on this form is collected under the authority of the Immigration and Refugee Protection Act and will be use to maintain a record of applications and Sponsorship Undertakings by private sponsors in Canada according to the requirements of the Act. It will be retained in the Personal Information Bank CIC PPU 008 identified in Infosource. It may be shared with other organizations in accordance with the consistent use of information under the Privacy Act. Under the Privacy Act and the Access to Information Act, individuals have the right to protection of and access to their personal information. Details on these matters are available at infosource.gc.ca and through the Immigration, Refugees and Citizenship Canada Call Centre. Infosource is also available at Public Libraries in Canada.