PROTECTED WHEN COMPLETED - B

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REQUEST FOR A CHANGE OF SEX OR GENDER IDENTIFIER

I, , born on in ,
(current legal name of applicant in full) (YYYY-MM-DD) (city, state/province, country)

previously held a temporary resident document (Visitor Visa, Temporary Resident Permit, Study Permit, or Work Permit) and am now applying for permanent

residence and I request a change in sex or gender identifier from to

OR

am a permanent resident who is applying for Canadian citizenship and I request a change in sex or gender identifier from

to

OR

request a change in sex or gender identifier from to

my Certificate of Canadian Citizenship

my Permanent Resident Card

my document issued to a Protected Person

By signing below, I acknowledge that I may encounter difficulties with the officials of other countries and/or airlines if my Immigration, Refugees and
Citizenship Canada (IRCC) document shows the requested sex or gender identifier, especially if it is different from my other identification, including my
passport or travel document, or is different from my physical appearance, and that I may be subjected to secondary inspections at the border. It is hereby
understood, and agreed, that IRCC, the Government of Canada or any representative of the Canadian Government will not be liable for any damages caused
or alleged to be caused as a result of the indication of that sex or gender identifier on my IRCC document. I agree not to make any claims or demands against
IRCC, or any representative of the Canadian government in respect of any potential damages.

Name of applicant (current legal name in full) Signature of applicant Date (YYYY-MM-DD)

If co-signature of parent(s)/legal guardian(s) is required as per your application:

If a change of sex or gender identifier is being requested for an individual under 18 years of age, both the applicant and their parent or legal guardian will need
to sign and provide proof of parentage or legal guardianship, as stipulated within the appropriate jurisdiction. A signature from a parent or legal guardian is
required for the purpose of applying for a document on behalf of a minor.
(Please attach separate sheet of paper if additional space is required)

Name of parent/legal guardian (current legal name in full) Signature of parent/legal guardian Date (YYYY-MM-DD)

Signed at:

city/town/village state/province country

CIT 0404 (06-2019) E (DISPONIBLE EN FRANÇAIS - CIT 0404 F)