41
EC 50055
(11/2014)

Oath of Residence Certificate
Electoral district

  
On the List: Oath of Residence Certificate only

Polling division

 Not on the List: Registration Certificate required
1.

Filled in by:

 Registration Officer

 Poll Clerk

Elector information (elector requiring an attestation as to residence)
Seq. no.

Family name 

Given name(s)

Street address

Attestor information (elector attesting to the residence of the elector identified above)
Seq. no.

2.

Family name 

Given name(s)

Street address

To be completed with the Deputy Returning Officer

Oral warning
Every person who is a Canadian citizen and is 18 years of age or older on election day is qualified as an elector.
It is an offence for an elector to:
•  vote or attempt to vote at an election knowing that they are not qualified as an elector;
•  knowingly register to vote at the advance poll or on polling day in a name that is not their own;
•  knowingly register to vote in a polling division in which they are not ordinarily resident;
•  register to vote at the advance poll or on polling day in an electoral district knowing that they are not qualified as an elector or 
entitled to vote in the electoral district;
•  compel, induce or attempt to compel or induce another person to make a false or misleading statement relating to that other
person’s qualification as an elector for the purposes of that other person registering and voting at the advance poll or on 
polling day;
•  attest to the residence of more than one elector at an election;
•  attest to another elector’s residence when their own residence has been attested to at the same election; or
•  falsely take an oath under the Canada Elections Act.
When an elector is convicted by a court of an offence listed above, the court may impose a fine of up to $50,000, imprisonment 
 for a term of not more than five years, or both. The penalty imposed will depend on the offence.
Elector: written oath ➏a
I am ordinarily resident at the address appearing in section 1.
[If the electoral event underway is a by-election]
I declare that I have been a resident of this electoral district since
________ and will continue to reside in the electoral district until 
election day.

As required by sections 143.1, 161.1 and 169.1 of the
Canada Elections Act, I have been orally advised of the
qualifications of an elector, relevant offences under the 
Act and the penalties that may be imposed by a court on
conviction for these offences.
All statements made on this form are true and correct.
Elector’s signature:

Attestor: written oath ➏b
I declare that:
•  I know the elector personally;
•  the elector resides at the address appearing in section 1;
•  I know the elector resides in my polling division;
•  I have not attested to the residence of another elector at
this election; and

As required by sections 143.1, 161.1 and 169.1 of the
Canada Elections Act, I have been orally advised
of relevant offences under the Act and the penalties
that may be imposed by a court on conviction for
these offences.
Attestor’s signature:

•  my own residence has not been attested to at this election.

3.

Deputy Returning Officer

Name (please print)

Signature

Date

YYYY-MM-DD

Your personal information contained in the Oath of Residence Certificate is collected under the Canada Elections Act for electoral purposes.
The form must be completed in order to allow an elector without proof of residence to vote in a federal election. This form may be reviewed by 
an independent third party as part of an audit required by the Canada Elections Act.
You have the right to the protection of your personal information pursuant to the Privacy Act. You also have the right to file a complaint with the 
Privacy Commissioner of Canada regarding Elections Canada’s handling of your personal information. Your personal information is retained under
Personal Information Bank (PIB) Elections PPU 037. A description of the PIB can be found at www.infosource.gc.ca.

EC 50055 Oath of Residence Certificate Fr_En 2014 .indd 2

10/23/14 2:00 PM