Foreign Ownership of Land Regulations (SOR/79-416)

I (We)

of

(full address including street, municipality and country.)

SOLEMNLY DECLARE THAT:

• • 1 (name of corporation(s)) of

  

  (mailing address)

  is (are) the transferee(s), transmittee(s), caveator(s) or lessee(s) named in the above described instrument; will hold the interest in the land beneficially and not as a trustee(s) and not on behalf of any person; and is (are) not a “foreign controlled corporation(s)” as defined in the Foreign Ownership of Land Regulations. I am a person authorized under section 22(2) of the Foreign Ownership of Land Regulations to sign on behalf of the transferee(s), transmittee(s), caveator(s) or lessee(s) named in the above described instrument.

• • 2 The true consideration paid or payable in respect of the transactionFootnote ^* is as follows:

  (give full details of purchase or rental as applicable, including total price paid)

• • 3 The present value of the landFootnote ^*, in my opinion, is $  

  (“land includes buildings and all other improvements affixed to the land”)

• • 4 The Appendix “A” annexed hereto correctly sets forth the required information for the corporation as of the date of this declaration. Information on shares for a public corporation may be computed as of a specific time as long as that time is within 3 months of the date of the transaction being registered, however, the balance of the declaration must be as of the date the declaration is sworn.

  • Return to footnote ^*Answer required only for transmissions, caveats and leases.

AND I (WE) MAKE THIS SOLEMN DECLARATION conscientiously believing it to be true, and knowing that it is of the same force and effect as if made under oath.

This is Appendix “A” to the Statutory Declaration of declared before me the day of 19 .

A Commissioner for Oaths

• Note: This Appendix is necessary only for a corporation with share capital. Limited Partnerships, Banks, Trust Companies and Insurance Companies do not have to complete this Appendix.

SHAREHOLDERS

List of Shareholders owning 5% or more of the outstanding shares: (Name and address)	Non-foreign controlled corporation, Canadian Citizen or Permanent ResidentFootnote for 1Yes or No	Number and Class of Share	% of Total Outstanding Shares	To the best of my knowledge the shareholder is the Beneficial Owner and controls the Rights Attached to the Shares Yes or NoFootnote for 2

• Return to footnote ¹If a permanent resident(s), Date Landed: , Port of Entry: , Birth Date: , and his (her or their) previous country of permanent residency was: .

• Return to footnote ² If any of the shares are held in trust or any of the rights attached to the shares are controlled through a contract or other arrangement by a person who does not own the share then list the person(s), who is (are) the ultimate beneficial owner(s) or who controls the rights attached to the shares, stating his (her or their) citizenship status and if a permanent resident the information as in one above.

List of Beneficial Owners of, or owners of the rights attached to, 5% or more of the outstanding shares: (name, address and citizenship status)