Solemn declaration for the estate representative

Large-print version of official source

Solemn declaration for the estate representative (PDF 227.53 KB)

Complete this form if you want to start or continue an appeal on behalf of a deceased person.

1 – Contact information for the estate representative

First name

Last name

Social Security Tribunal (SST) file number

Home / business address (No., Street, R.R.)

Apt. / unit

City / town

Province / Territory

If “Other,” please specify

Postal code

Country

Phone number (with area code)

Email address (optional)

2 – Solemn declaration

, solemnly declare that:

2. I’m applying to start or continue the deceased person’s appeal at the SST on behalf of the estate.

3. Please check the box that applies to you:

I’m authorized to administer the deceased person’s estate. I’m either attaching proof of this authority now or I have already provided it to the SST.

I have attached a copy of one of the following documents:

the will naming me as the executor, estate trustee, or liquidator
the court order appointing me as the administrator, estate trustee, or liquidator
the designation or agreement naming me as the liquidator

If other individuals may be authorized to administer the deceased person’s estate, I have their consent to continue the appeal before the SST on behalf of the estate.

I don’t have any document that confirms my authority to administer the deceased person’s estate. The deceased person didn’t have a will, and no one is authorized to administer the estate.

My relationship to the deceased person is:

3 – Signature of the estate representative

I make this solemn declaration believing it to be true and knowing that it has the same legal effect as if I had sworn an oath.

Signature

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