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4IP 3 - Appendix B - Annex 6
RAP Change of Status Form
Client Name:
___________________________
FOSS/CLIENT’S ID No. _____________________
CIC (HOF) FILE No. _________________________
Telephone No: (_____) ___________________
D.O.B. (DD-MMM-YY) _______________________
1. ADDRESS CHANGE
New Address: _______________________________________________________________________
City: ____________________ Province/Country: _______________ Postal Code: _______________
New Telephone No: _______________________
Date of Move: ___________________________
»
Reason for Move to another Province:
Relatives/Friends
Employment
Language
Other: __________________________________________________________________
»
Rent Amount $___________
Are you sharing this cost with anyone? Yes
No
If yes, name of person with whom you are sharing the rent: ______________________________
NOTE: Provide RENTAL AGREEMENT and/or a suitable receipt of your rental costs.
»
Previous Address: _______________________________________________________________
City: _____________________ Province: _____________
Postal Code: ________________
NOTE: If you are moving from Quebec to another province, please provide proof of residency
with a copy of your IMM5292 (confirmation of permanent residence) and a copy of the letter from
Quebec Social Services.
2. EMPLOYMENT CHANGE
Are you starting
full-time employment? Yes
No
Start Date: _____________________
»
Are you
starting
part-time employment? Yes
No
Start Date: _____________________
For part-time employment, how many hours are you working/day or week? ________________
What is your rate of pay?
(Per hour)
Pay-Period Type: _________________________ (Weekly, Bi-weekly, Semi-Monthly, Monthly)
Employer’s Name: _________________________________________________________________
Employer’s Address: ______________________________________________________________
Telephone Number: (____)______________________
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IP 3 - Appendix B - Annex 6
RAP Change of Status Form
Client Name:
___________________________
FOSS/CLIENT’S ID No. _____________________
CIC (HOF) FILE No. _________________________
Telephone No: (_____) ___________________
D.O.B. (DD-MMM-YY) _______________________
1. ADDRESS CHANGE
New Address: _______________________________________________________________________
City: ____________________ Province/Country: _______________ Postal Code: _______________
New Telephone No: _______________________
Date of Move: ___________________________
»
Reason for Move to another Province:
Relatives/Friends
Employment
Language
Other: __________________________________________________________________
»
Rent Amount $___________
Are you sharing this cost with anyone? Yes
No
If yes, name of person with whom you are sharing the rent: ______________________________
NOTE: Provide RENTAL AGREEMENT and/or a suitable receipt of your rental costs.
»
Previous Address: _______________________________________________________________
City: _____________________ Province: _____________
Postal Code: ________________
NOTE: If you are moving from Quebec to another province, please provide proof of residency
with a copy of your IMM5292 (confirmation of permanent residence) and a copy of the letter from
Quebec Social Services.
2. EMPLOYMENT CHANGE
Are you starting
full-time employment? Yes
No
Start Date: _____________________
»
Are you
starting
part-time employment? Yes
No
Start Date: _____________________
For part-time employment, how many hours are you working/day or week? ________________
What is your rate of pay?
(Per hour)
Pay-Period Type: _________________________ (Weekly, Bi-weekly, Semi-Monthly, Monthly)
Employer’s Name: _________________________________________________________________
Employer’s Address: ______________________________________________________________
Telephone Number: (____)______________________
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IP 3 - Appendix B - Annex 6
Are you ending
full-time employment?
Yes
No
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Last day worked: ______________
Last pay cheque received: ______________
Are you ending
part-time employment?
Yes
No
Last day worked: ______________
Last pay cheque received: ______________
3. RECEIPT OF FUNDS FOR TRAINING / SCHOOL
What school are you attending? _____________________________________________________
»
Start Date:
__
Have you received any of the following items?
If yes, please include dollar amount, breakdown of the items covered and details of how funds
are provided – directly to client, directly against student loan balance or directly to school.
Training Allowance
Student Grant or Scholarship
Student Bursary or Award
Other
4. CHANGE IN FAMILY SIZE
BIRTH:
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Are you expecting a baby? Yes
No
If yes, please provide a doctor’s note with the estimated date of arrival.
NOTE: Once the baby is born, please provide a copy of the form issued by the hospital stating
the baby’s name and date of birth.
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FAMILY DEPENDENTS:
Have any of your dependents moved?
Yes
No
If yes, please provide their full names(s) and date(s) of birth. _____________________________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Have you or any of your dependents left Canada for a period of time? Yes
No
If yes, please provide full name(s), date(s) of birth, date of departure and return. ____________
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
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MARRIAGE:
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IP 3 - Appendix B - Annex 6
Have you married since your arrival in Canada?
Yes
No
If yes, please provide copy of the marriage certificate.
What is the immigration status of your spouse? ________________________________________
Is your spouse living in Canada?
Yes
No
SEPARATION:
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Have you separated from your spouse since your arrival in Canada?
Yes
No
If yes, please provide date of separation: _____________________________________________
Full name of spouse: ______________________________________________________________
Birth date of spouse: _______________________________________________________________
DEATH:
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Has a member of your family passed away? Yes
No
If yes, please provide a copy of the death certificate.
Funeral Home name and address: ____________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
5. OTHER CHANGES
NAME CHANGE:
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Have you or any family member ‘legally” or otherwise changed your name?
Yes
No
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INCARCERATION (JAIL):
Have you been incarcerated (jailed)? Yes
No
If yes, please provide a copy of your conviction report.
Has any other member of your family been incarcerated? Yes
No
If yes, please provide a copy of their conviction report.
HOSPITALIZATION:
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Have you been hospitalized? Yes
No
If yes, please provide a note from your doctor confirming the length of stay, if longer than one
month.
TRAVEL OUTSIDE OF CANADA:
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When will you be leaving Canada? Date: _________________
What is your expected date of return? ___________________
Please provide a copy of your airline ticket.
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IP 3 - Appendix B - Annex 6
______________________________________________
_________________________
RAP Client Signature
Date
Please return this completed form within 10 days of any change in status to the address below.
Note: address changes are required 1 month in advance of the move date.
Local CIC Office Address Here
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