Schedule A: Background / Declaration Form (IMM 5669)

Read these instructions if you need help filling out any sections of this form in the Permanent Residence Portal.

Schedule A – Background/Declaration (IMM 5669)

For refugee claimants in Canada: Only family members included in your application for refugee protection who are with you in Canada must be included using this form.

Personal details

Family and given names

Family name is also known as last name or surname.

Given names are also known as first name and middle name. Do not use initials.

Enter your names exactly as they appear on your passport, travel document or identity document.

Questionnaire

If you answered “Yes” to one or more of these questions, you must enter an explanation in the details field.

Education

If you didn’t earn a diploma, leave the “Type of certificate or diploma issued” field blank.

Personal history

If you don’t account for all time periods, it may delay the processing of your application.

Personal history - Activity

Examples of activity types

• employment (please specify)
• unemployed
• educational activity

Personal history - Status in country or territory

Examples of status

• work visa
• citizen
• study visa
• visitor visa

Exception: If you have not worked in the past 10 years (for example, you’re retired), you must provide details of your personal history since the age of 18. The resume or Curriculum Vitae (CV) that you provide with your application will help verify the information in this question.

Membership and association with organizations

Examples of organizations

• political organizations
• social organizations
• youth or student organizations
• trade unions
• professional associations

Don’t use abbreviations.

Government positions

Examples of government positions

• civil servant
• judge
• police officer
• employee in a security organization

Don’t use abbreviations.

Military and paramilitary service

If you don’t account for all time periods, it may delay the processing of your application.

Addresses

Write out addresses in full without using any abbreviations. Use the apartment or unit number, if this applies.

Example: 999 Family Street, Unit #3, Ottawa, Ontario, Canada, K3J 9T5

Authority to disclose personal information

Declaration of applicant

Read all of the statements in all sections carefully and type your full name into the blue field (this is your digital signature).

By signing, you certify that you fully understand the questions asked, and that the information you provided is complete, truthful, and correct.

Download the form

Schedule A: Background / Declaration Form [IMM 5669] (PDF, 0.2 MB)

Last updated: May 2021

Complete the form

Schedule A – Background/Declaration (IMM 5669)

This form must be completed by:

• you, the principal applicant;
• your spouse or common-law partner (whether accompanying you to Canada or not), and
• your dependent children aged 18 years or older (whether accompanying you to Canada or not).

For refugee claimants in Canada: Only family members included in your application for refugee protection who are with you in Canada must complete this form.

Question 1

Enter your full family name (surname or last name) exactly as it is shown on your passport, travel or identity document.

Enter all of your given name(s) (first, second or more) exactly as they are shown on your passport, travel or identity document. Do not use initials.

Question 2

Enter your name in your native language or script (if applicable).

For example: Arabic, Cyrillic, Chinese, Farsi, Korean, Japanese characters or Chinese commercial/telegraphic code.

Question 3

Enter your date of birth. If you do not know your complete date of birth, please use an “*” (asterisk) to fill in the spaces for the unknown year, month or day. For example, if the day and month of your date of birth is unknown you could enter 1964/*/*.

Question 4

Provide your father’s personal details including their:

• family name (surname or last name),
• given name(s),
• date of birth,
• town or city of birth,
• country of birth,
• date of death (if applicable).

Question 5

Provide your mother’s personal details including their:

• family name (surname or last name),
• given name(s),
• date of birth,
• town or city of birth,
• country of birth,
• date of death (if applicable).

Question 6

Answer each question by checking the appropriate box.

If you answered “Yes” to one or more of these questions, you must explain what happened in the space provided. If you need more space, attach a separate sheet of paper.

For questions 7-12, when answering:

• Do not use abbreviations
• Do not leave gaps in time

If a question doesn’t apply to you, write “N/A” in the question.

If you need more space, attach a separate sheet of paper.

Important information: Processing will be delayed if you do not account for all periods of time.

Question 7

Education

Enter the number of years of formal education you have completed at each of the levels indicated.

Provide the details about each secondary and post-secondary educational institution you attended, including the:

• period of time that you attended the institution,
• name of the institution,
• city and country,
• type of certificate or diploma issued, and
• field of study.

If no diploma was issued, write “N/A”. If you need more space, attach a separate sheet of paper.

Question 8

Provide the details of your personal history since the age of 18, or the past 10 years, whichever is most recent.

Start with the most recent information.

If you were working:

• under “Activity”, enter your occupation or job title.
• make sure you provide a specific job title
• If your job title is not clear, provide a brief list of your duties

If you were not working:

• Explain what you were doing (for example: unemployed, studying, travelling, retired, in detention, etc.)

If you were outside your country of nationality, enter your status of the country you were in.

Important information: Please ensure that you do not leave any gaps in time. Failure to account for all time periods will result in a delay in the processing of your application.

Question 9: Membership in organizations

If you were or still are a member of an association or organizing, enter the names here.

This includes:

• political organizations,
• social organizations,
• youth or student organizations,
• trade unions, and
• professional associations.

If you were not a member of an association or organization, do not write “not applicable”. Instead, enter: “I have never been a member of an organization or association”.

Question 10

Enter any government positions you have held in the past such as:

• Civil servant;
• Judge;
• Police officer;
• Employee in a security organization;
• Etc.

Enter “NONE” in the box if you have not been a member of an association or organization.

Include:

• the name of the country and the level of jurisdiction (examples: national, regional or municipal),
• the name of the department or the branch you worked for, and
• activities and/or positions that you held.

Note: Do not use abbreviations.

Question 11

Give complete details about your military or paramilitary service (if applicable). Provide the details of your military or paramilitary service for each of the countries whose armed forces you served in. If you were not in any military or paramilitary service, write “NONE”. Do not leave gaps in time.

Question 12

Enter the residential addresses where you have lived since your 18th birthday or the past 10 years, whichever is most recent, complete with the postal code. Do not use P.O. Box addresses.

Authority to disclose personal information
Declaration of applicant

Read all of the statements in all sections carefully. Sign and date in the boxes provided. By signing, you certify that you fully understand the questions asked, and that the information you have provided is complete, truthful, and correct. If you do not sign and date, the application will be returned to you.