Statutory Declaration for a Change of Sex Designation on a ... · I understand that the Government of Ontario cannot guarantee that a birth certificate or certified copy of a birth

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Office of the Registrar General PO Box 3000 189 Red River Road Thunder Bay ON P7B 5W0

Statutory Declaration for a Change of Sex Designation on a Birth Registration of an Adult Section 36, Vital Statistics ActIn the matter of the birth registration of:

Name on Birth Registration:Last Name or Single Name First Name Middle Name(s)

Formerly(If name has been legally changed since birth, enter name before the change. Otherwise leave this blank.)

Place of Ordinary Residence:City/Town/Village Province/Territory/State Country

Date of Birth:Year

/Month

/Day

Place of Birth:City/Town/Village in Ontario

List the full birth names of all parents as listed on the applicants birth registration:Last Name or Single Name First and Middle Name(s)

1.

2.

3.

4.

Declaration: I,Current Legal Name of Applicant, in Full

,

Solemnly declare that:1. I make this application to change the sex designation on my birth registration From (select only one): Male Female X (X means the applicant does not identify exclusively as male or female) To (select only one): Male Female X (X means the applicant does not identify exclusively as male or female) If you are applying to change to X, please complete this section:

I understand that the Government of Ontario cannot guarantee that a birth certificate or certified copy of a birth registration with a designation of X will be accepted by organizations in Ontario or by other jurisdictions.

2. I have assumed (or have always had) the gender identity that accords with the requested change in sex designation.3. I am living full-time in the gender identity that accords with the requested change in sex designation and intend to maintain that gender identity.4. I am providing the following documentation in support of this application (select one of the following):

a letter from a practising physician or a psychologist authorized to practise in Canada.

a document or certificate issued by a jurisdiction in which I was domiciled or ordinarily resident.

other medical evidence as I am not domiciled or ordinarily resident in Canada.

a certificate signed by a practising physician authorized to practise in Canada, that complies with the current requirements of s. 36 (2)(a) or (b) under the Vital Statistics Act.

5. All existing birth certificates, birth certificates with parental information and certified copies of birth registration have been returned with this declaration.

6. This application is not made for an improper purpose.

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.Declared before me at:

in the of

this day of , 20 .

A Commissioner, etc.

Signature of Applicant

(sign, print name, and affix commissioner's stamp or describe office, if stamp not required)

Personal information contained on this form and other documents submitted with this application is collected under the authority of the Vital Statistics Act, R.S.O. 1990 c.V.4, as amended, and may be used to register and record births, stillbirths, deaths, marriages or changes of name, make additions, corrections or amendments to registrations, provide certified copies, extracts, certificates, search notices, photocopies; and for statistical, research, medical, security and law enforcement, adoption and adoption disclosure purposes. The Ministry of Government and Consumer Services may verify with medical professionals or jurisdictions the information they have provided on the documents in support of this application. It is an offence to willfully make or cause to be made a false statement on this form and other documents submitted with this application. Questions about this collection should be directed to: The Deputy Registrar General, Office of the Registrar General, 189 Red River Road, P.O. Box 3000, Thunder Bay, ON P7B 5W0. Telephone: Outside Toronto but within North America 1-800-461-2156 or in Toronto or outside North America 416-325-8305, TTY/Teletypewriter (for the hearing impaired) 416-325-3408 or Fax: 807-343-7459.

Statutory Declaration for a Change of Sex Designation on a Birth Registration of an Adult

11324E (2018/04) Queen's Printer for Ontario, 2018

Disponible en franais


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Government of Ontario

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Service Ontario

Office of the Registrar General

PO Box 3000189 Red River RoadThunder Bay ON P7B 5W0


Section 36,Vital Statistics Act

In the matter of the birth registration of:

Name on Birth Registration:

Formerly

Place of Ordinary Residence:

Date of Birth:

/

/

Place of Birth:

List thefull birth names ofall parents as listed on the applicants birth registration:

Last Name or Single Name

First and Middle Name(s)

Declaration:

I,

,

Solemnly declare that:

1. I make this application to change the sex designation on my birth registration

From (select only one):

To (select only one):

If you are applying to change to X, please complete this section:

2. I have assumed (or have always had) the gender identity that accords with the requested change in sex designation.

3. I am living full-time in the gender identity that accords with the requested change in sex designation and intend to maintain that gender identity.

4. I am providing the following documentation in support of this application (select one of the following):

5. All existing birth certificates, birth certificates with parental information and certified copies of birth registration have been returned with this declaration.

6. This application is not made for an improper purpose.

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.

Declared before me at:

in the

of

this

day of

, 20

.

(sign, print name, and affix commissioner's stamp or describe office, if stamp not required)

Personal information contained on this form and other documents submitted with this application is collected under the authority of theVital Statistics Act, R.S.O. 1990 c.V.4, as amended, and may be used to register and record births, stillbirths, deaths, marriages or changes of name, make additions, corrections or amendments to registrations, provide certified copies, extracts, certificates, search notices, photocopies; and for statistical, research, medical, security and law enforcement, adoption and adoption disclosure purposes. The Ministry of Government and Consumer Services may verify with medical professionals or jurisdictions the information they have provided on the documents in support of this application. It is an offence to willfully make or cause to be made a false statement on this form and other documents submitted with this application. Questions about this collection should be directed to: The Deputy Registrar General, Office of the Registrar General, 189 Red River Road, P.O. Box 3000, Thunder Bay, ON P7B 5W0. Telephone: Outside Toronto but within North America 1-800-461-2156 or in Toronto or outside North America 416-325-8305, TTY/Teletypewriter (for the hearing impaired) 416-325-3408 or Fax: 807-343-7459.

8.0.1291.1.339988.308172

Alexandra Schmidt

2012/09/20

Ministry of Government Services

Statutory Declaration for a Change of Sex Designation on a Birth Registration of an AdultSection 36, Vital Statistics ActOffice of the Registrar General

Sheleigh Bober


2012/09/20

Clear: Print: saveForm: TextField1: Name on Birth Registration. Last Name or Single Name.: Name on Birth Registration. First Name.: Name on Birth Registration. Middle Name or Names.: Declaration: I. Enter Current Legal Name of Applicant, in Full.: Place of Ordinary Residence. Country: Enter the last two digits of the year. : Date of Birth. Month. Enter month two digits.: Date of Birth. Day. Enter day two digits.: Place of Birth. City, Town or Village in Ontario: List the full birth names of all parents as listed on the applicants birth registration: 4. Last Name or Single Name.: List the full birth names of all parents as listed on the applicants birth registration: 4. First and Middle Name(s).: Solemnly declare that: 1. I make this application to change the sex designation on my birth registration. If you are applying to change to X, please complete this section: I understand that the Government of Ontario cannot guarantee that a birth certificate or certified copy of a birth registration with a designation of X will be accepted by organizations in Ontario or by other jurisdictions.: Solemnly declare that: 1. I make this application to change the sex designation on my birth registration. To. Female: Solemnly declare that: 1. I make this application to change the sex designation on my birth registration. To. X (X means the applicant does not identify exclusively as male or female): a letter from a practising physician or a psychologist authorized to practise in Canada. : a document or certificate issued by a jurisdiction in which I was domiciled or ordinarily resident. : other medical evidence as I am not domiciled or ordinarily resident in Canada. : a certificate signed by a practising physician authorized to practise in Canada, that complies with the current requirements ofs. 36 (2)(a) or (b) under the Vital Statistics Act. : Declared before me at: Enter place of declaration. : in the. Enter type of place. : of. Enter name of place. : this. Enter day number using two digits. : day of. Enter the name of the month. : A Commissioner, etc. (sign, print name, and affix commissioner's stamp or describe office, if stamp not required) : Signature of Applicant. Print and then sign. :

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Statutory Declaration for a Change of Sex Designation on a ... · I understand that the Government of Ontario cannot guarantee that a birth certificate or certified copy of a birth