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CONTRACT RESPECTING FINANCIAL SELF-SUFFICIENCY

Principal Applicant (excluding live-in caregivers and persons authorized to apply for permanent residence in Canada on humanitarian grounds)

INSTRUCTIONS
Who must fill out this form The principal applicant (including a foreign student or foreign worker living temporarily in Qubec) and his or her accompanying spouse or de facto spouse, if any, who applies for a Certificat de slection du Qubec (Quebec selection certificate) under the subclass of Skilled Workers, Entrepreneurs or Self-Employed Persons. If you are a live-in caregiver or if you are authorized by Citizenship and Immigration Canada to apply for permanent residence in Canada on humanitarian grounds, this form is not intended for you. You must instead fill out the form entitled Contract respecting financial self-sufficiency Live-in caregiver and person authorized to apply for permanent residence in Canada on humanitarian grounds. What is the Contract respecting financial self-sufficiency The Contract respecting financial self-sufficiency is a legal act by which you undertake, for the entire term of the contract, to provide for your basic needs and, where applicable, those of your spouse or de facto spouse and your dependent children (including those who are Canadian citizens) who accompany you to Qubec. The term of the contract is three months starting on the date of your arrival in Qubec as a permanent resident. Basic needs include food, clothing, personal necessities and housing-related expenses. You must sign this contract or else your application for a selection certificate will not be accepted. For more information, see the Act respecting immigration to Qubec (R.S.Q., c. I-0.2) and the Regulation respecting the selection of foreign nationals (R.R.Q. 1981, c. M-23.1, r. 2). How to fill out this form Section A identifies you and, where applicable, your spouse or de facto spouse and dependent children (including Canadian citizens) who are accompanying you. Answer the questions accurately. Section B of the contract. Read the contract carefully and sign it. Don't forget to enter, at Point 1, the amount at your disposal when you arrive in Qubec to support your needs and, where applicable, the needs of your spouse or de facto spouse and of your dependent children. To learn the minimum amount required in your situation, use the calculation table below (use the greyed spaces to enter the amounts that apply to your situation and to calculate your minimum required amount). TABLE FOR CALCULATING THE MINIMUM AMOUNT REQUIRED FOR THE ESSENTIAL NEEDS OF PRINCIPAL FAMILY UNITS FOR THE THREE-MONTH PERIOD FOLLOWING ARRIVAL IN QUBEC (AMOUNTS IN EFFECT FROM JANUARY 1 TO DECEMBER 31, Number of accompanying dependent children (including ones who are Canadian citizens) 0 1 Under 18 years old State the number of additional children: 18 years or older State the number of children: 2 3 Principal applicant without spouse or accompanying spouse $2,956 $3,973 $4,484 $4,996 Add $512 per additional child Add $1,379 per child Principal applicant with accompanying spouse $4,336 $4,857 $5,242 $5,627 Add $385 per additional child Add $1,379 per child Minimum required $

2014)

Calculation of minimum amount required for your basic needs

Examples of calculations based on accompanying persons: - Principal applicant with spouse and 2 children under 18 years old = $5,242 - Principal applicant with spouse and one child under 18 years old and one child age 18 or older = $4,857 + $1,379 = $6,236 - Principal applicant with spouse and four children under 18 years old = $5,627 + $385 = $6,012 - Principal applicant without spouse but with one child under 18 years old and 2 children age 18 or older = $3,973 + (2 X $1,379) = $6,731

Ministre de lImmigration et des Communauts culturelles

A-0522-OA (2014-01)

Save to Officio

CONTRACT RESPECTING FINANCIAL SELF-SUFFICIENCY

Principal Applicant (excluding live-in caregivers and persons authorized to apply for permanent residence in Canada on humanitarian grounds)
Reserved for Administration Individual Reference No. : File No. :

Section A IDENTIFICATION OF THE PRINCIPAL APPLICANT

Family name at birth: ____________________________________________________________ First name: ____________________________________________________ Family name after marriage (where applicable) : ______________________________________ Sex: Marital status: Single Married  De facto spouse Separated Divorced
N/A
Hernandez Hernandez

German Rene

 M

1971 05 28 Date of birth: ____________________________

Year / Month / Day

Marriage annulled

Widowed

Residence address: ________________________________________________________________________________________________________________________________

26 BALTANAS, COLONIA SAN JUAN XALPA, DELEGACION IZTAPALAPA, C.P. 09850, MEXICO, D.F.

______________________________________________________________________________________________ ______________________________________________________
Telephone number: ______________________________________________
55 56 13 96 31

IDENTIFICATION OF ACCOMPANYING SPOUSE OR DE FACTO SPOUSE AND DEPENDENT CHILDREN

Family Name (at birth) FIRST NAME SEX DATE OF BIRTH
Year / Month / Day

ADDRESS (if different from the principal applicant)

A - Spouse or de facto spouse

Penaloza Gaspar Claudia

1974

06

16

B - Dependent children (including children who are Canadian citizens)

1 2 3 4 5 6

Hernandez Penaloza

Eglantina

1995

08

15

Hernandez Penaloza

Anwar

2002

06

03

Ministre de lImmigration et des Communauts culturelles

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Section B CONTRACT
I acknowledge having read the information on this form and I understand the nature and scope of the contract respecting financial self-sufficiency. Consequently: 1. I declare that, for the term of this contract, which is three months from the date of my arrival in Qubec as a permanent resident, I will have financial resources at least equal to the amount prescribed in Appendix C of the Regulation respecting the selection of foreign nationals, adjusted for 3 months, to meet basic needs, 5242 specifically an amount of CA $ _______________________ . 2. I undertake to provide for my basic needs and those of other persons identified in Section A for the full term of the contract. 3. I undertake to reimburse the Government of Qubec for any amount that it may pay me or other persons identified in Section A, in the form of last resort financial assistance, in accordance with applicable legislation, throughout the full term of the contract. 4. I authorize the Ministre de l'Immigration et des Communauts culturelles to transmit information about this contract to the Ministre de l'Emploi et de la Solidarit sociale, if any application is made for last resort financial assistance for myself or for any persons identified in Section A. 5. If I belong to the Skilled Worker subclass, I acknowledge having been informed that the Ministre, after examining my situation and that of my spouse or de facto spouse, may choose to change the principal applicant if the situation is more advantageous for the award of points in the selection grid. In this case, only the person among us who will be the principal applicant will be bound by the commitments mentioned above.

In witness whereof, I have signed at ___________________________________________________________ on ____________________________

City Year / Month / Day

_____________________________________________________________________________________________________________________________
Signature of the principal applicant

In witness whereof, I have signed at ___________________________________________________________ on ____________________________

City Year / Month / Day

_____________________________________________________________________________________________________________________________
Signature of the spouse or de facto spouse (signature required only if he or she is accompanying a principal applicant in the Skilled Worker subclass)

Please keep a signed copy of this form and return the other signed copy with your application for a Quebec selection certificate.

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