Canada
Province or Territory of .

in the matter of a contract bearing no.
and dated the (insert day of contract bearing) day of (insert month of contract bearing) (insert year of contract bearing) .
between his majesty the king in right of Canada, and
(insert full name of Contractor) ,
hereinafter referred to as the Contractor,
for (Description and location of work) ,
and in the matter of

To wit:

I, (Print or type name of Declarant) , of (Declarant's address) do solemnly declare:

(1) that I am (Print or type Declarant's title or position with the Contractor or state that Declarant is the Contractor) and as such have personal knowledge of the said Contract and of the facts and matters stated herein.

(2) (indicate by checkmark - √ in applicable box)

that, up to the date of the attached Progress Claim, the contractor has complied with all its lawful obligations in respect of the Labour Conditions, discharged all its lawful obligations to workmen in respect of the work contracted for and has discharged all its lawful obligations to its subcontractors and suppliers except for holdback monies properly retained, payments deferred by agreement or amounts whithheld by reason of legitimate dispute which have been identified to the party or parties, from whom payment has been withheld.

that, up to the effective date of the certificate of substantial completion, the contractor has complied with all its lawful obligations in respect of the Labour Conditions, fully discharged all its lawful obligations to workmen, its subcontractors and suppliers in respect of the work contracted for and, in the case of a non-resident contractor, to the provincial tax authority respecting the payment of all applicable provincial taxes arising from or related to the performance of the work under the Contract, except for holdback monies properly retained, payments deferred by agreement or amounts whithheld by reason of legitimate dispute which have been identified to the party or parties, from whom payment has been withheld.

that, up to the date of the certificate of completion, the contractor has complied with all its lawful obligations in respect of the Labour Conditions, fully discharged all its lawful obligations to workmen, its subcontractors and suppliers in respect of the work contracted for and discharged and satisfied all lawful claims against it that arose out of the performance of this Contract except for holdback monies properly retained, payments deferred by agreement or amounts whithheld by reason of legitimate dispute which have been identified to the party or parties, from whom payment has been withheld.

(3) that the total amounts of (if nil, state nil) were withheld by reason of legitimate dispute for which a statement is attached as part of this declaration, explaining in detail the reason(s) of the dispute(s) and identifying the party or parties from whom payment has been withheld.

And I 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, and by virtue of the canada evidence act.

Declared before me at (insert location) this (instert day) day of (insert month) , (insert year)

________________________________________
(Signature of person before whom the Declaration is made)

(Print name of person before whom the Declaration is made)

A Notary Public, Commissioner, etc. (Please state authority for receiving Declarations-Notaries to affix Notarial Seal)

________________________________________
(Signature of Declarant)

Notice

If this Declaration is not complete in every detail, it will be returned for completion and payment will be delayed. The making of a false or fraudulent declaration is a contravention of the Criminal Code of Canada, and could carry, upon conviction penalties including fines or imprisonment.

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