PROTECTED WHEN COMPLETED – B

PAGE 1 OF 2

DECLARATION
concerning a lost, stolen, inaccessible, damaged or found Canadian travel document
WARNING to applicant—Any false or misleading statement on this form or relating to any document in support of your travel document application,
including concealment of any material fact, may lead to refusal to issue or revocation of a travel document and be grounds for criminal prosecution.
TYPE OR PRINT IN CAPITAL LETTERS using black or dark blue ink.
1 PERSONAL INFORMATION AS INDICATED ON MOST RECENT CANADIAN TRAVEL DOCUMENT
The travel document was issued in: ✖ My name Child's name
Surname (last name)
RAVELO
Given name(s)
KERREN ALEXANDRA
Date of birth Place of birth
Year Month Day CANADA ON
TORONTO
1994 04 27 City Country Prov./Ter./State (if applicable)
Document number (if known) Date of issue (if known) Place of issue (if known)
Year Month Day CARACAS VENEZUELA
City Country
Signature of applicant Date Signed at
Year Month Day
City Country

Is the travel document being submitted with your declaration? ✖ No – Continue to section 2 Yes – Go to section 3

INFORMATION CONCERNING A VALID CANADIAN TRAVEL DOCUMENT NO LONGER IN MY POSSESSION

2 Note: Incomplete descriptions may result in the delay or refusal of your application. If insufficient space, attach a separate signed and dated sheet.
The travel document listed in section 1 is no longer in my possession because (please provide a detailed explanation as to why you are not
submitting the travel document and what has happened to it)
I WAS STAYING IN A MOTEL IN MIAMI AND I LEAVE MY PASSPORT THERE IN THE ROOM FEW HOURS.
WHEN I RETURNED, MY PASSPORT WAS NOWHERE TO BE FOUND.

I have made the following efforts to recover this travel document (please explain)
I HAD LOOK EVERYWHERE IN MY ROOM. I SEARCHED ALL MY THINGS AND IN DIDN'T FIND IT THEN I CALLED
THE POLICE AND MADE A REPORT.

Date this document was lost, stolen or became inaccessible

Year Month Day
2016 05 25
This document was last used on Location
Year Month Day MIAMI FL UNITED STATES OF AMERICA
2016 05 01 City Country
Was a police report filed?
✖ Yes Date of report Report number Name of police service
Year Month Day
2016 05 25 2016018336 HIALEAH POLICE DEPARTMEN

No Please provide the reason for not filing a police report

Were any other provincial or federal identification documents lost or stolen?

Yes ✖ No

PPTC 203E (2014-11) R2 (AUSSI DISPONIBLE EN FRANÇAIS — PPTC 203F)

 PAGE 2 OF 2
INFORMATION CONCERNING A DAMAGED OR FOUND CANADIAN TRAVEL DOCUMENT
3
Note: If insufficient space, attach a separate signed and dated sheet.
Detailed circumstance of how the travel document was damaged or found

Explain why you are applying for a replacement travel document

Date travel document was damaged or found Location

Year Month Day
City Country
Reminder: A travel document application form must also be completed if a replacement travel document is required. Please note that the travel
document specified in this form cannot be used for the simplified renewal process.

4 DECLARATION OF APPLICANT
Surname (last name)

Given name(s) Daytime telephone number Date of birth

Year Month Day

DECLARATION—I solemnly declare that, to my knowledge, the statements made in this declaration are true. Should I ever regain possession of
the Canadian travel document reported in section 1, I will return it immediately to the Passport Program or if abroad to the nearest Government of
Canada office. I acknowledge that a Canadian travel document once reported lost, stolen, inaccessible, damaged or found is no longer
valid and is NOT to be used for any travel. I understand multiple occurrences of Lost/Stolen or Damaged travel documents may result in either
the refusal to issue a replacement travel document, or if approved, a severely limited validity of the replacement travel document. I also
acknowledge that additional requirements may apply, such as demonstrating the need to be issued a travel document. I declare that I have read
and understood the WARNING to applicant at the top of page 1.
Signature of applicant Date Signed at
Year Month Day

City Country

FOR OFFICE USE ONLY

Based on the information provided by the applicant on this form, the travel document has been identified as

Lost Stolen Damaged Mutilated Inaccessible Found

Name of officer who reviewed the above information (stamp recommended) Date
Year Month Day

Travel document number Date of issue Place of issue

Year Month Day

City Country

To obtain the most recent version of this form, visit our website at passportcanada.gc.ca.

PPTC 203E (2014-11) R2