|NOTE: To the best of your knowledge, please indicate the following:|
|Name of the Department:|
|Name of the Program:|
|Estimate of amount claimed:|
Note: All deletions or alterations are to be initialled by the applicant and the witnesses.
IN THE MATTER OF THE ESTATE OF:
(Full name of deceased)
1 I,(Full name of applicant), age , of(Address)
in(City, town or village) in the Province of(Name of province) Postal Code
make an application in accordance with section 3 of the Payments to Estates Regulations, 1996.
2 That I am the(Relationship) of the late(Full name of deceased) who died at(City, town or village) in the Province of (Name of province) on the(Date) day of(Month), (Year) a copy of whose death certificate is attached to this application, and who died: (check one only) without a will with a will, a copy is attached.
(Note: if the will is a holograph, provide proof that it has been probated.)
3 That at the time of death, the deceased had his/her permanent residence in (City, town or village), (Province).
4 That I am (check one only)
5 That the information provided in this application is correct.
6 That I agree to indemnify and save harmless Her Majesty in right of Canada from any loss or damage that may be incurred as a consequence of making the payment to me.
7 That I agree to return any overpayment or erroneous payment, which constitutes a debt due to the Her Majesty in right of Canada.
(Applicant - signature)(Witness 1 - signature)(Witness 1 - signature)
(Witness 1 - Name in capital letters)(Witness 2 - Name in capital letters)
(City, town or village), in the Province of (Name of province)
(Date) day of (Month), (Year).
Note: The witnesses must have no interest in the estate of the deceased and must not be related to the applicant.
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