Immigration and Refugee Board of Canada (IRB) – Refugee Protection Division (RPD) Basis of Claim Form (for persons claiming refugee protection in Canada) (RPD.02.01) Instructions
This form contains 236 fields organized into 72 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| 2(b) Harm/Mistreated/Threatened - Explanation Details | ||
| 2(b) Harm/Mistreated/Threatened Explanation | Text |
Provide a detailed explanation of why you believe you would be harmed, mistreated, or threatened if you returned to your country, including what would happen, who would harm/threaten you, the reason, and any relevant dates, names, and places. Fill only if '2(b) Yes' is 'Yes'.
Depends on:
2(b) Yes
|
| 2(b) Harm/Mistreated/Threatened - Yes/No | ||
| 2(b) Yes | Radiobutton |
Check this box if you believe you would be harmed, mistreated, or threatened by any person or group if you returned to your country.
|
| 2(b) No | Radiobutton |
Check this box if you do not believe you would be harmed, mistreated, or threatened by any person or group if you returned to your country.
|
| 2(c) Asked Authorities for Protection/Assistance - Explanation Details | ||
| 2(c) Authorities Asked for Protection/Assistance - Explanation | Text |
Provide a detailed explanation of whether you asked any authorities or organizations in your country for protection or assistance, including whom you approached, what steps you took, what happened as a result, and relevant dates, names, and places. Fill only if '2(c) Asked authorities for protection/assistance - Yes', '2(c) Asked authorities for protection/assistance - No' is 'Yes' or is 'No' (any of fields).
Depends on:
2(c) Asked authorities for protection/assistance - Yes, 2(c) Asked authorities for protection/assistance - No
|
| 2(c) Asked Authorities for Protection/Assistance - Yes/No | ||
| 2(c) Asked authorities for protection/assistance - Yes | Radiobutton |
Check this box if you asked any authorities (such as the police) or any other organization in your country to protect or assist you.
|
| 2(c) Asked authorities for protection/assistance - No | Radiobutton |
Check this box if you did not ask any authorities (such as the police) or any other organization in your country to protect or assist you.
|
| Applicant Name and Date of Birth | ||
| Given or first name(s) | Text |
Enter your given name(s) or first name(s) exactly as they appear on your passport.
|
| Family or last name(s) / surname(s) | Text |
Enter your family name(s) or surname(s) exactly as they appear on your passport.
|
| Date of birth | Date |
Enter your date of birth.
|
| Canadian Office Where Applied | ||
| Canadian Office Where Applied | Text |
Enter the name of the Canadian office where you applied for the visa to enter Canada.
|
| Child Age 6 or Younger Risk Explanation (Detailed) | ||
| Child Age 6 or Younger Risk Explanation (Detailed) | Text |
Provide a detailed explanation of why you believe the child aged six or younger would be at risk of harm, mistreatment, or threats if returned to their country, including information specific to the child's situation. Fill only if 'Children under 18 claiming refugee protection with you: Yes' is 'Yes'.
Depends on:
Children under 18 claiming refugee protection with you: Yes
|
| Child Under 18 Situation: Not the Child's Parent (Consent/Legal Documents Explanation) | ||
| Not the Child's Parent - Consent or Legal Documents Explanation | Text |
Describe any legal documents or written consent you have that allows you to care for or travel with the child, or explain why you do not have such documents. Fill only if 'You are not the child's parent' is 'Yes'.
Depends on:
You are not the child's parent
|
| You are not the child's parent | Checkbox |
Check this box if a child under 18 is claiming refugee protection with you and you are not the child's parent. Fill only if 'Children under 18 claiming refugee protection with you: Yes' is 'Yes'.
Depends on:
Children under 18 claiming refugee protection with you: Yes
|
| Child Under 18 Situation: Parent and Other Parent in Canada | ||
| Child Under 18: You are the child’s parent and the other parent is in Canada | Checkbox |
Check this box if a child under 18 is claiming refugee protection with you and you are the child’s parent while the other parent is in Canada. Fill only if 'Children under 18 claiming refugee protection with you: Yes' is 'Yes'.
Depends on:
Children under 18 claiming refugee protection with you: Yes
|
| Child Under 18 Situation: Parent but Other Parent Not in Canada (Consent/Legal Documents Explanation) | ||
| You are the child's parent but the other parent is not in Canada | Checkbox |
Check this box if a child under 18 is claiming refugee protection with you and you are the child's parent but the other parent is not currently in Canada. Fill only if 'Children under 18 claiming refugee protection with you: Yes' is 'Yes'.
Depends on:
Children under 18 claiming refugee protection with you: Yes
|
| Consent or Legal Documents Explanation (Other Parent Not in Canada) | Text |
Describe any legal documents or written consent you have that allows you to care for or travel with the child when the other parent is not in Canada, or explain why you do not have such documents. Fill only if 'You are the child's parent but the other parent is not in Canada' is 'Yes'.
Depends on:
You are the child's parent but the other parent is not in Canada
|
| Children Under 18 Claiming Refugee Protection With You (Yes/No) | ||
| Children under 18 claiming refugee protection with you: Yes | Radiobutton |
Check this box if there are children who are less than 18 years old claiming refugee protection with you.
|
| Children under 18 claiming refugee protection with you: No | Radiobutton |
Check this box if there are no children who are less than 18 years old claiming refugee protection with you.
|
| Citizenship Info (Fifth Row) | ||
| Fifth Row Citizenship Country | Text |
Enter the name of the country for the fifth citizenship entry (row (e)).
|
| Fifth Row Present Citizenship Status | Text |
Enter your current status for the fifth listed country of citizenship (e.g., citizen, former citizen, dual citizen).
|
| Fifth Row How Citizenship Was Acquired | Text |
Describe how you acquired citizenship for the fifth listed country (e.g., by birth, by marriage, by naturalization).
|
| Fifth Row Date Citizenship Was Acquired | Date |
Enter the date you acquired citizenship for the fifth listed country.
|
| Citizenship Info (First Row) | ||
| First Citizenship Country | Text |
Enter the name of the first country of which you are or have been a citizen.
|
| First Citizenship Present Status | Text |
Enter your current citizenship status for the first listed country (e.g., current citizen, former citizen).
|
| First Citizenship Acquisition Method | Text |
Describe how you acquired citizenship for the first listed country (e.g., by birth, by marriage, by naturalization).
|
| First Citizenship Acquisition Date | Date |
Enter the date on which you acquired citizenship for the first listed country.
|
| Citizenship Info (Fourth Row) | ||
| Fourth Citizenship Country | Text |
Enter the country for the fourth citizenship entry (row d).
|
| Fourth Citizenship Present Status | Text |
Enter your current citizenship status for the fourth listed country (e.g., citizen, former citizen).
|
| Fourth Citizenship Acquisition Method | Text |
Describe how you acquired citizenship for the fourth listed country (e.g., by birth, by marriage, naturalization).
|
| Fourth Citizenship Acquisition Date | Date |
Enter the date you acquired citizenship for the fourth listed country.
|
| Citizenship Info (Second Row) | ||
| Second Row - Country of Citizenship | Text |
Enter the country for which you are or have been a citizen in the second row of the citizenship table.
|
| Second Row - Present Status | Text |
Enter your present citizenship status for the country listed in the second row (e.g., current citizen, former citizen).
|
| Second Row - How Citizenship Was Acquired | Text |
Describe how you acquired citizenship for the second-row country (e.g., by birth, by marriage, naturalization).
|
| Second Row - Date Citizenship Was Acquired | Date |
Provide the date on which you acquired citizenship for the second-row country.
|
| Citizenship Info (Sixth Row) | ||
| Citizenship (Sixth Row) - Country | Text |
Enter the name of the country of which you are or have been a citizen for the sixth row of the citizenship table.
|
| Citizenship (Sixth Row) - Present Status | Text |
Enter your current citizenship status for the country listed in the sixth row (e.g., citizen, former citizen, dual citizen).
|
| Citizenship (Sixth Row) - How Citizenship Was Acquired | Text |
Describe how you acquired citizenship for the country listed in the sixth row (e.g., by birth, by marriage, by naturalization).
|
| Citizenship (Sixth Row) - Date Citizenship Was Acquired | Date |
Provide the date you acquired citizenship for the country listed in the sixth row.
|
| Citizenship Info (Third Row) | ||
| Third Row Citizenship Country | Text |
Enter the country of which you are or have been a citizen for the third row of the citizenship list.
|
| Third Row Citizenship Present Status | Text |
Enter your current citizenship status for the country listed in the third row (e.g., current citizen, former citizen).
|
| Third Row Citizenship Acquisition Method | Text |
Describe how you acquired citizenship for the country listed in the third row (e.g., by birth, by marriage, by naturalization).
|
| Third Row Date Citizenship Was Acquired | Date |
Enter the date on which you acquired citizenship for the country listed in the third row.
|
| Claimant Identification | ||
| Client I.D. Number | Text |
Enter the claimant's unique client identification number as shown on official IRB/Immigration documents.
|
| Claimant's given name(s) and family name(s) | Text |
Enter the claimant's full legal given name(s) followed by their family name(s) exactly as they appear on identity or immigration documents.
|
| Contact Address in Canada | ||
| Street number and name | Text |
Enter the street number and street name for your contact address in Canada.
|
| Apartment/room/floor number | Text |
Enter your room, floor, or apartment/unit number for your contact address in Canada, if applicable.
|
| City | Text |
Enter the city for your contact address in Canada.
|
| Province | Combobox |
Enter the province for your contact address in Canada.
Alberta
Nova Scotia
Manitoba
Nunavut
Ontario
Quebec
British Columbia
Newfoundland and Labrador
New Brunswick
Prince Edward Island
Northwest Territories
Yukon
Saskatchewan
|
| Postal code | Text |
Enter the postal code for your contact address in Canada.
|
| Telephone number (including area code) | Text |
Enter your telephone number in Canada, including the area code.
|
| Counsel (Q9a) - Counsel Helped Complete Form Yes/No | ||
| Q9a - Counsel helped complete form - Yes | Radiobutton |
Check this box if your counsel helped you complete this Basis of Claim form. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Q9a - Counsel helped complete form - No | Radiobutton |
Check this box if your counsel did not help you complete this Basis of Claim form. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Counsel (Q9a) - Counsel Will Represent at Hearing Yes/No | ||
| Q9a - Counsel will represent you at hearing: Yes | Radiobutton |
Check this box if your counsel will be representing you at your refugee protection hearing. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Q9a - Counsel will represent you at hearing: No | Radiobutton |
Check this box if your counsel will not be representing you at your refugee protection hearing. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Counsel (Q9a) - Have Counsel Yes/No | ||
| Q9(a) Have counsel - Yes | Radiobutton |
Check this box if you have counsel (e.g., a lawyer, immigration consultant, family member, or other person) who will help you with your refugee protection claim before the Refugee Protection Division.
|
| Q9(a) Have counsel - No | Radiobutton |
Check this box if you do not have counsel who will help you with your refugee protection claim before the Refugee Protection Division.
|
| Counsel (Q9b-9i) - Counsel Contact Information | ||
| Q9b Counsel Name | Text |
Enter the full name of your counsel (e.g., lawyer, immigration consultant, or other representative). Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Q9c Counsel Address | Text |
Enter your counsel’s complete mailing address (street address and any suite/unit information). Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Q9d Counsel City | Text |
Enter the city for your counsel’s address. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Q9e Counsel Province | Combobox |
Enter the province for your counsel’s address. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Alberta
Nova Scotia
Manitoba
Nunavut
Ontario
Quebec
British Columbia
Newfoundland and Labrador
New Brunswick
Prince Edward Island
Northwest Territories
Yukon
Saskatchewan
Depends on:
Q9(a) Have counsel - Yes
|
| Q9f Counsel Postal Code | Text |
Enter the postal code for your counsel’s address. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Q9g Counsel Telephone Number | Text |
Enter your counsel’s telephone number, including the area code. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Q9h Counsel Fax Number | Text |
Enter your counsel’s fax number, including the area code. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Q9i Counsel Email Address | Text |
Enter your counsel’s email address. Fill only if 'Q9(a) Have counsel - Yes' is 'Yes'.
Depends on:
Q9(a) Have counsel - Yes
|
| Counsel (Q9k) - Lawyer/Consultant Credentials | ||
| Q9k - Lawyer (or notary if practising in Quebec) | Checkbox |
Check this box if your counsel is a lawyer, or a notary if they practise in Quebec.
|
| Q9k Province of Membership | Combobox |
Enter the province where the counsel is licensed or registered (e.g., the province of the law society or regulatory body). Fill only if 'Q9k - Lawyer (or notary if practising in Quebec)' is 'Yes'.
Alberta
Nova Scotia
Manitoba
Nunavut
Ontario
Quebec
British Columbia
Newfoundland and Labrador
New Brunswick
Prince Edward Island
Northwest Territories
Yukon
Saskatchewan
Depends on:
Q9k - Lawyer (or notary if practising in Quebec)
|
| Q9k - Member of Immigration Consultants of Canada Regulatory Council | Checkbox |
Check this box if your counsel is a regulated immigration consultant who is a member of the Immigration Consultants of Canada Regulatory Council.
|
| Q9k Membership Identification Number | Text |
Enter the counsel's membership or licence identification number issued by their professional regulatory body. Fill only if 'Q9k - Lawyer (or notary if practising in Quebec)', 'Q9k - Member of Immigration Consultants of Canada Regulatory Council' is 'Yes' (any).
Depends on:
Q9k - Lawyer (or notary if practising in Quebec), Q9k - Member of Immigration Consultants of Canada Regulatory Council
|
| Counsel (Q9l) - Family Member Relationship | ||
| Q9(l) Counsel is a family member | Checkbox |
Check this box if the person acting as your counsel is a family member (and you will specify the relationship).
|
| Q9(l) Family Member Relationship | Text |
Enter the relationship between you and your counsel if your counsel is a family member (e.g., spouse, parent, sibling). Fill only if 'Q9(l) Counsel is a family member', 'Q9(l) Counsel type - Other' is 'Yes' (any).
Depends on:
Q9(l) Counsel is a family member, Q9(l) Counsel type - Other
|
| Counsel (Q9l) - Other Counsel Type | ||
| Q9(l) Counsel type - Other | Checkbox |
Check this box if your counsel does not fit any of the listed categories (lawyer/notary, immigration consultant, or family member).
|
| Countries Where You Are at Risk of Serious Harm | ||
| Country Where You Are at Risk of Serious Harm (a) | Text |
Enter the name of a country where you believe you are at risk of serious harm.
|
| Country Where You Are at Risk of Serious Harm (b) | Text |
Enter the name of another country where you believe you are at risk of serious harm.
|
| Country Where You Are at Risk of Serious Harm (c) | Text |
Enter the name of another country where you believe you are at risk of serious harm.
|
| Country Where You Are at Risk of Serious Harm (d) | Text |
Enter the name of another country where you believe you are at risk of serious harm.
|
| Date you left your country | ||
| Date you left your country | Date |
Enter the date on which you left your country.
|
| Declaration A (Claimant) - Date | ||
| Declaration A (Claimant) Date | Date |
Enter the date on which the claimant signs Declaration A.
|
| Declaration B (Claimant) - Date | ||
| Declaration B (Claimant) Date | Date |
Enter the date on which the claimant signs Declaration B.
|
| Family Relative (Eighth Row) | ||
| Eighth Relative - Family/Last Name(s) | Text |
Enter the eighth relative's family name(s) or surname(s).
|
| Eighth Relative - Given/First Name(s) | Text |
Enter the eighth relative's given or first name(s).
|
| Eighth Relative - Relationship | Text |
Enter how this person is related to you (for example, mother, son, spouse, or sister).
|
| Eighth Relative - Date of Birth | Date |
Enter the eighth relative's date of birth.
|
| Eighth Relative - Citizenship(s) | Text |
Enter the eighth relative's citizenship(s).
|
| Eighth Relative - Place and Country of Residence | Text |
Enter the city/town (place) and country where the eighth relative currently lives.
|
| Family Relative (Eleventh Row) | ||
| Eleventh Row Relative Family Name(s) / Surname(s) | Text |
Enter the family or last name(s) (surname(s)) of the relative listed in the eleventh row.
|
| Eleventh Row Relative Given Name(s) | Text |
Enter the given or first name(s) of the relative listed in the eleventh row.
|
| Eleventh Row Relationship | Text |
Enter the relative’s relationship to you (for example, mother, son, spouse) for the eleventh row entry.
|
| Eleventh Row Date of Birth | Date |
Provide the relative’s date of birth for the eleventh row entry.
|
| Eleventh Row Citizenship(s) | Text |
Enter the relative’s citizenship(s) for the eleventh row entry.
|
| Eleventh Row Place and Country Where They Live | Text |
Enter the city/town (or place) and country where the relative currently lives for the eleventh row entry.
|
| Family Relative (Fifth Row) | ||
| Fifth Relative Family/Last Name(s) | Text |
Enter the family name(s) or surname(s) of the fifth listed family member/relative.
|
| Fifth Relative Given/First Name(s) | Text |
Enter the given or first name(s) of the fifth listed family member/relative.
|
| Fifth Relative Relationship | Text |
Enter the relationship of the fifth listed family member/relative to you (for example, mother, son, spouse).
|
| Fifth Relative Date of Birth | Date |
Enter the date of birth of the fifth listed family member/relative.
|
| Fifth Relative Citizenship(s) | Text |
Enter the citizenship or citizenships held by the fifth listed family member/relative.
|
| Fifth Relative Place and Country of Residence | Text |
Enter the city/town (place) and country where the fifth listed family member/relative currently lives.
|
| Family Relative (First Row) | ||
| Family Relative (First Row) - Family/Last Name(s) | Text |
Enter the family name(s) or surname(s) of the family member listed in the first row.
|
| Family Relative (First Row) - Given/First Name(s) | Text |
Enter the given name(s) or first name(s) of the family member listed in the first row.
|
| Family Relative (First Row) - Relationship | Text |
Enter your relationship to this person (for example, mother, father, spouse, son, or sister).
|
| Family Relative (First Row) - Date of Birth | Date |
Enter this family member’s date of birth.
|
| Family Relative (First Row) - Citizenship(s) | Text |
Enter this family member’s citizenship or citizenships.
|
| Family Relative (First Row) - Place and Country of Residence | Text |
Enter the place (city/town) and country where this family member currently lives.
|
| Family Relative (Fourth Row) | ||
| Fourth Family Relative - Family/Last Name | Text |
Enter the family or last name (surname) of the fourth listed relative.
|
| Fourth Family Relative - Given/First Name | Text |
Enter the given or first name(s) of the fourth listed relative.
|
| Fourth Family Relative - Relationship | Text |
Enter the relative’s relationship to you (for example, mother, son, brother, spouse).
|
| Fourth Family Relative - Date of Birth | Date |
Enter the date of birth of the fourth listed relative.
|
| Fourth Family Relative - Citizenship(s) | Text |
Enter the citizenship(s) held by the fourth listed relative.
|
| Fourth Family Relative - Place and Country of Residence | Text |
Enter the city/place and country where the fourth listed relative currently lives.
|
| Family Relative (Ninth Row) | ||
| Ninth Row - Family/Last Name(s) | Text |
Enter the relative’s family or last name(s) (surname[s]).
|
| Ninth Row - Given/First Name(s) | Text |
Enter the relative’s given or first name(s).
|
| Ninth Row - Relationship | Text |
Enter the relative’s relationship to you (for example, mother, son, spouse, sister).
|
| Ninth Row - Date of Birth | Date |
Enter the relative’s date of birth.
|
| Ninth Row - Citizenship(s) | Text |
Enter the relative’s citizenship(s).
|
| Ninth Row - Place and Country of Residence | Text |
Enter the city/town (or place) and country where the relative currently lives.
|
| Family Relative (Second Row) | ||
| Family Relative (Second Row) - Family/Last Name(s) | Text |
Enter the relative’s family name(s) or surname(s) for the second row of the family list.
|
| Family Relative (Second Row) - Given/First Name(s) | Text |
Enter the relative’s given or first name(s) for the second row of the family list.
|
| Family Relative (Second Row) - Relationship | Text |
Specify the relative’s relationship to you (for example, mother, spouse, son) for the second row.
|
| Family Relative (Second Row) - Date of Birth | Date |
Enter the relative’s date of birth for the second row of the family list.
|
| Family Relative (Second Row) - Citizenship(s) | Text |
List the relative’s citizenship(s) for the second row of the family list.
|
| Family Relative (Second Row) - Place and Country of Residence | Text |
Enter the city/town (place) and country where the relative currently lives for the second row.
|
| Family Relative (Seventh Row) | ||
| Seventh Family Member Last Name(s) | Text |
Enter the family member’s family or last name(s)/surname(s) for the seventh row.
|
| Seventh Family Member Given Name(s) | Text |
Enter the family member’s given or first name(s) for the seventh row.
|
| Seventh Family Member Relationship | Text |
Enter the person’s relationship to you (for example, mother, son, spouse) for the seventh row.
|
| Seventh Family Member Date of Birth | Date |
Enter the family member’s date of birth for the seventh row.
|
| Seventh Family Member Citizenship(s) | Text |
Enter the family member’s citizenship(s) for the seventh row.
|
| Seventh Family Member Place and Country of Residence | Text |
Enter the place and country where the family member lives for the seventh row.
|
| Family Relative (Sixth Row) | ||
| Sixth Row Relative Family/Last Name(s) | Text |
Enter the family or last name(s) (surname[s]) of the relative listed in the sixth row.
|
| Sixth Row Relative Given/First Name(s) | Text |
Enter the given or first name(s) of the relative listed in the sixth row.
|
| Sixth Row Relative Relationship | Text |
Enter the relative’s relationship to you (for example, mother, father, son, sister) for the sixth row.
|
| Sixth Row Relative Date of Birth | Date |
Enter the date of birth of the relative listed in the sixth row.
|
| Sixth Row Relative Citizenship(s) | Text |
Enter the citizenship(s) held by the relative listed in the sixth row.
|
| Sixth Row Relative Place and Country of Residence | Text |
Enter the city/town (place) and country where the relative listed in the sixth row currently lives.
|
| Family Relative (Tenth Row) | ||
| Tenth Relative Family/Last Name(s) | Text |
Enter the family or last name(s) (surname) of the tenth listed relative.
|
| Tenth Relative Given/First Name(s) | Text |
Enter the given or first name(s) of the tenth listed relative.
|
| Tenth Relative Relationship | Text |
Enter the relationship of the tenth listed relative to you (e.g., mother, son).
|
| Tenth Relative Date of Birth | Date |
Enter the tenth listed relative's date of birth.
|
| Tenth Relative Citizenship(s) | Text |
Enter the citizenship(s) held by the tenth listed relative.
|
| Tenth Relative Place and Country of Residence | Text |
Enter the place (city/town) and country where the tenth listed relative lives.
|
| Family Relative (Third Row) | ||
| Family Relative (Third Row) - Family/Last Name | Text |
Enter the family name(s) or surname(s) of the family member listed on the third row.
|
| Family Relative (Third Row) - Given/First Name | Text |
Enter the given or first name(s) of the family member listed on the third row.
|
| Family Relative (Third Row) - Relationship | Text |
Enter the person’s relationship to you (for example, mother, son, spouse, sister).
|
| Family Relative (Third Row) - Date of Birth | Date |
Enter the date of birth of the family member listed on the third row.
|
| Family Relative (Third Row) - Citizenship(s) | Text |
Enter the citizenship(s) held by the family member listed on the third row.
|
| Family Relative (Third Row) - Place and Country of Residence | Text |
Enter the city/town (or place) and country where this family member currently lives.
|
| Fifth Previous Protection Claim | ||
| Fifth Previous Protection Claim - Family Name | Text |
Enter the family or last name (surname) of the person who made the fifth previous refugee protection or asylum claim.
|
| Fifth Previous Protection Claim - Given Name | Text |
Enter the given or first name of the person who made the fifth previous refugee protection or asylum claim.
|
| Fifth Previous Protection Claim - Relationship | Text |
Enter the relationship of the person who made the fifth previous claim to you (e.g., mother, son).
|
| Fifth Previous Protection Claim - Date of Claim | Date |
Provide the date when the fifth previous refugee protection or asylum claim was made.
|
| Fifth Previous Protection Claim - Country or UNHCR | Text |
Enter the country where the fifth previous claim was made or indicate UNHCR if it was made through the United Nations High Commissioner for Refugees.
|
| Fifth Previous Protection Claim - Result | Text |
Enter the outcome of the fifth previous claim (e.g., accepted, rejected, not completed).
|
| Fifth Previous Protection Claim - IRB File Number and/or CIC Client ID | Text |
Enter the IRB file number and/or CIC client ID number associated with the fifth previous claim, if available.
|
| First Previous Protection Claim | ||
| First Previous Protection Claim - Family/Last Name | Text |
Enter the family or last name (surname) of the person who previously claimed refugee protection or asylum.
|
| First Previous Protection Claim - Given/First Name | Text |
Enter the given or first name of the person who previously claimed refugee protection or asylum.
|
| First Previous Protection Claim - Relationship | Text |
Enter the relationship of the person to you (for example, mother, son).
|
| First Previous Protection Claim - Date of Claim | Date |
Enter the date when the refugee protection or asylum claim was made.
|
| First Previous Protection Claim - Country or UNHCR | Text |
Enter the country where the claim was made or indicate UNHCR if it was made through the United Nations High Commissioner for Refugees.
|
| First Previous Protection Claim - Result | Text |
Enter the outcome of the claim (for example, accepted, refused, withdrawn).
|
| First Previous Protection Claim - IRB File Number / CIC Client ID | Text |
Enter the IRB file number and/or the CIC client ID number associated with the claim, if available.
|
| Fourth Previous Protection Claim | ||
| Fourth Claimant Family/Last Name | Text |
Enter the family or last name (surname) of the person for the fourth previous protection claim.
|
| Fourth Claimant Given/First Name | Text |
Enter the given or first name(s) of the person for the fourth previous protection claim.
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| Fourth Claimant Relationship | Text |
Enter the relationship of the person to you (for example, mother, son) for the fourth previous protection claim.
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| Fourth Claim Date | Date |
Enter the date the fourth previous protection/asylum claim was made.
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| Fourth Claim Country or UNHCR Office | Text |
Enter the country where the fourth previous protection/asylum claim was made or indicate UNHCR if applicable.
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| Fourth Claim Result | Text |
Enter the outcome/result of the fourth previous protection/asylum claim.
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| Fourth Claim IRB File No. / CIC Client ID No. | Text |
Enter the IRB file number and/or CIC client ID number associated with the fourth previous protection/asylum claim.
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| Harmed/Mistreated/Threatened (Yes/No) | ||
| Harmed/Mistreated/Threatened — Yes | Radiobutton |
Check this box if you or any family member have ever been harmed, mistreated, or threatened by any person or group.
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| Harmed/Mistreated/Threatened — No | Radiobutton |
Check this box if neither you nor any family member have ever been harmed, mistreated, or threatened by any person or group.
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| Harmed/Mistreated/Threatened Explanation | ||
| Explanation of harm, mistreatment or threats | Text |
Describe in detail what happened to you and your family, including when and where the harm, mistreatment or threats occurred, who caused them, why you believe they happened, whether others in similar situations experienced the same treatment, and any relevant names, dates and places. Fill only if 'Harmed/Mistreated/Threatened — Yes' is 'Yes'.
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| Interpreter (Q10b) - Language and Dialect | ||
| Q10b Interpreter Language | Text |
Enter the language you want the interpreter to use for your hearing and related communications, or write N/A if you do not need an interpreter.
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| Q10b Interpreter Dialect | Text |
Enter the specific dialect of the language you want the interpreter to use, or write N/A if not applicable.
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| Interpreter's Declaration - Interpreter Details and Date | ||
| Interpreter full name | Text |
Enter the interpreter's full name as it should appear on this declaration.
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| Language interpreted to | Text |
Enter the language (and dialect, if applicable) that the interpreter translated the form into for the claimant.
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| Interpreter declaration date | Date |
Enter the date the interpreter signed this declaration.
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| IRB Office Use - RPD File Number | ||
| RPD File Number (IRB office use) | Text |
Enter the RPD file number assigned by the IRB office for this claim (the official file identifier used by the IRB).
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| Language (Q10a) - Official Language Choice | ||
| Q10a Official language: English | Checkbox |
Check this box if you want the IRB to use English when communicating with you (including at your hearing and in documents).
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| Q10a Official language: French | Checkbox |
Check this box if you want the IRB to use French when communicating with you (including at your hearing and in documents).
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| Language, Interpreter and Declaration | ||
| Your signature | Signature |
Claimant signs here to certify that all information in the Basis of Claim form is true and complete (first signature field).
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| Your signature | Signature |
Claimant’s second signature if an interpreter was used. Sign after reviewing the interpreter’s declaration.
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| Interpreter's signature | Signature |
Interpreter signs here to certify that the interpretation of the Basis of Claim form was complete and accurate.
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| Languages and Dialects Spoken | ||
| Languages and dialects spoken (1g) | Text |
Enter all languages and dialects you speak (for example: English, Spanish - Castilian, Arabic - Levantine), separated by commas and including any regional varieties you can use.
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| Moved to Another Country Details (If Yes, Explain) | ||
| Moved to Another Country Details | Text |
Provide details about moving to another country (other than Canada) to seek safety, including the country name, when you moved there, how long you stayed, and whether you claimed refugee protection there (and if not, why not). Fill only if 'Moved to another country to seek safety — Yes' is 'Yes'.
Depends on:
Moved to another country to seek safety — Yes
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| Moved to Another Country to Seek Safety (Yes/No) | ||
| Moved to another country to seek safety — Yes | Radiobutton |
Check this box if you moved to another country (other than Canada) to seek safety.
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| Moved to another country to seek safety — No | Radiobutton |
Check this box if you did not move to another country (other than Canada) to seek safety.
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| Moved to another part of your country to seek safety (Yes/No & explanation) | ||
| Yes | Radiobutton |
Check this box if you moved to another part of your country to seek safety.
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| No | Radiobutton |
Check this box if you did not move to another part of your country to seek safety.
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| Safety Relocation Explanation | Text |
Explain in detail whether you moved to another part of your country to seek safety and why you could not live in the place you moved to (or anywhere else in your country) today. Fill only if 'Yes', 'No' is 'Yes' (any fields selection).
Depends on:
Yes, No
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| Nationality / Ethnic and Racial Group or Tribe | ||
| Nationality / Ethnic or racial group / Tribe | Text |
Enter your nationality and, if applicable, the name of your ethnic, racial group or tribe (for example: country of citizenship and/or ethnic or tribal identity) as a short text.
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| Other Important Details for Refugee Protection Claim | ||
| Other Important Details for Refugee Protection Claim | Text |
Provide any additional information you believe is important to support your claim for refugee protection.
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| Passport Sex Identification (Male/Female/Other and Specify) | ||
| Male | Radiobutton |
Check this box if the sex identified on your passport is Male.
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| Other | Radiobutton |
Check this box if the sex identified on your passport is Other, and use the adjacent line to specify the designation shown on the passport.
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| Female | Radiobutton |
Check this box if the sex identified on your passport is Female.
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| Passport sex (Other - specify) | Text |
Enter the sex designation shown on your passport when the printed option is not Male or Female (i.e., specify the 'Other' value exactly as it appears on the passport). Fill only if 'Other' is 'Yes'.
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| Reason for Visa Refusal | ||
| Reason for Visa Refusal | Text |
Enter the reason your Canadian visa application was refused. Fill only if 'Visa Application Accepted - No' is 'Yes'.
Depends on:
Visa Application Accepted - No
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| Reason you left at that time (not sooner/later) | ||
| Reason you left at that time (not sooner/later) | Text |
Explain why you left your country when you did and why you could not leave sooner or at a later time.
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| Religion and Denomination or Sect | ||
| Religion / Denomination or Sect | Text |
Enter the name of your religion and, if applicable, your specific denomination or sect (for example: Christianity — Catholic, Islam — Sunni, Buddhism — Theravada, or write 'None' if you have no religion).
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| Second Previous Protection Claim | ||
| Second Previous Protection Claim - Family Name(s) | Text |
Enter the family or last name(s) (surname) of the person who made the second previous protection claim.
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| Second Previous Protection Claim - Given Name(s) | Text |
Enter the given or first name(s) of the person who made the second previous protection claim.
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| Second Previous Protection Claim - Relationship | Text |
Enter the person’s relationship to you (for example, mother, son) for the second previous protection claim.
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| Second Previous Protection Claim - Date of Claim | Date |
Enter the date when the second previous protection claim was made.
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| Second Previous Protection Claim - Country or UNHCR | Text |
Enter the country where the second previous protection claim was made or indicate UNHCR if applicable.
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| Second Previous Protection Claim - Result | Text |
Enter the outcome of the second previous protection claim.
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| Second Previous Protection Claim - IRB File Number / CIC Client ID | Text |
Enter the IRB file number and/or CIC client ID number associated with the second previous protection claim.
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| Self-Identified Sex/Gender (If Different From Passport) | ||
| Self-identified sex/gender | Text |
Enter the sex or gender you personally identify with (if different from the sex/gender shown on your passport).
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| Seventh Previous Protection Claim | ||
| Seventh Claim Family/Last Name(s) | Text |
Enter the family or last name(s) (surname[s]) of the person who made the seventh previous protection claim.
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| Seventh Claim Given/First Name(s) | Text |
Enter the given or first name(s) of the person who made the seventh previous protection claim.
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| Seventh Claim Relationship | Text |
Enter the relationship of this person to you (for example, mother, son) for the seventh previous protection claim.
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| Seventh Claim Date of Claim | Date |
Enter the date when the seventh previous protection claim was made.
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| Seventh Claim Country or UNHCR | Text |
Enter the country where the seventh previous protection claim was made or indicate UNHCR if it was made through the United Nations High Commissioner for Refugees.
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| Seventh Claim Result | Text |
Enter the outcome of the seventh previous protection claim (for example, accepted, rejected, not completed).
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| Seventh Claim IRB File No. / CIC Client ID No. | Text |
Enter the IRB file number and/or the CIC client ID number associated with the seventh previous protection claim, if available.
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| Sixth Previous Protection Claim | ||
| Sixth Claim Family Name(s) / Surname(s) | Text |
Enter the family or last name(s) (surname[s]) of the person who made the sixth previous protection claim.
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| Sixth Claim Given Name(s) | Text |
Enter the given or first name(s) of the person who made the sixth previous protection claim.
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| Sixth Claim Relationship | Text |
Enter the relationship of the person who made the sixth previous protection claim to you (e.g., mother, son).
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| Sixth Claim Date of Claim | Date |
Enter the date when the sixth previous protection or asylum claim was made.
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| Sixth Claim Country or UNHCR | Text |
Enter the country where the sixth previous protection claim was made or indicate UNHCR if it was made through the United Nations High Commissioner for Refugees.
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| Sixth Claim Result | Text |
Enter the outcome of the sixth previous protection claim (e.g., accepted, rejected, not completed).
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| Sixth Claim IRB File No. and/or CIC Client ID No. | Text |
Enter the IRB file number and/or the CIC client ID number associated with the sixth previous protection claim, if available.
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| Third Previous Protection Claim | ||
| Third Previous Protection Claim - Family/Last Name | Text |
Enter the family or last name (surname) of the person associated with the third previous protection/asylum claim.
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| Third Previous Protection Claim - Given/First Name | Text |
Enter the given or first name of the person associated with the third previous protection/asylum claim.
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| Third Previous Protection Claim - Relationship | Text |
Enter the relationship of this person to you (for example, mother, father, son, daughter).
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| Third Previous Protection Claim - Date of Claim | Date |
Enter the date when the third previous protection/asylum claim was made.
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| Third Previous Protection Claim - Country or UNHCR | Text |
Enter the country where the claim was made or indicate UNHCR if it was made through the United Nations High Commissioner for Refugees.
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| Third Previous Protection Claim - Result | Text |
Enter the outcome of the third previous protection/asylum claim (for example, accepted, refused, withdrawn).
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| Third Previous Protection Claim - IRB File Number / CIC Client ID | Text |
Enter the IRB file number and/or the CIC client ID number associated with the third previous protection/asylum claim.
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| Type of Canadian Visa Applied For | ||
| Work | Checkbox |
Check this box if the type of Canadian visa you applied for was a work visa/permit.
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| Visitor | Checkbox |
Check this box if the type of Canadian visa you applied for was a visitor visa.
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| Immigrant | Checkbox |
Check this box if the type of Canadian visa you applied for was an immigrant visa (permanent residence).
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| Student | Checkbox |
Check this box if the type of Canadian visa you applied for was a student visa/permit.
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| Other | Checkbox |
Check this box if the type of Canadian visa you applied for was not Work, Visitor, Immigrant, or Student.
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| Visa Application Accepted (Yes/No) | ||
| Visa Application Accepted - Yes | Radiobutton |
Check this box if the Canadian visa application was accepted.
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| Visa Application Accepted - No | Radiobutton |
Check this box if the Canadian visa application was not accepted.
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| Visa Application Date (if Yes) | ||
| Visa Application Date (if Yes) | Date |
Enter the date you applied for a visa to enter Canada (only if you answered YES to applying for a visa). Fill only if 'Visa application to enter Canada - Yes' is 'Yes'.
Depends on:
Visa application to enter Canada - Yes
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| Visa Application Refused Date | ||
| Visa Application Refused Date | Date |
Enter the date on which the visa application to enter Canada was refused. Fill only if 'Visa Application Accepted - No' is 'Yes'.
Depends on:
Visa Application Accepted - No
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| Visa Application to Enter Canada (Yes/No) | ||
| Visa application to enter Canada - Yes | Radiobutton |
Check this box if you applied for a visa to enter Canada.
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| Visa application to enter Canada - No | Radiobutton |
Check this box if you did not apply for a visa to enter Canada.
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| Visa Issued Date and Duration | ||
| Visa Issued Date and Duration | Text |
Enter the date the Canadian visa was issued and the duration (length of validity or stay) for that visa. Fill only if 'Visa Application Accepted - Yes' is 'Yes'.
Depends on:
Visa Application Accepted - Yes
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