Consent for Veterans Affairs Canada to Collect Personal Information from Third Parties
Provide your consent to allow third parties to share personal information with VAC. Complete all required fields and review the privacy notice.
CSDN ID
File No.
Last name
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First name
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Middle name(s)
Date of birth (yyyy-mm-dd)
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Month
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Day
Year
Date
Section A — Scope of consent
Scope of consent
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My complete file
The following specific information only
Specify the information to release (e.g., name of reports and any specific instructions)
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Section B — Parties authorized to release personal information to VAC
List parties authorized to release information to VAC
Section C — Declaration
Privacy Notice:
The personal information you provide on this form is collected under the authority of the Department of Veterans Affairs Act and will be used to determine eligibility for benefits and services. Your information may be shared with other federal or provincial government institutions, or third parties, as authorized by law. Failure to provide the requested information may result in a delay or inability to process your application. For more information about how your information will be used and protected, you may contact Veterans Affairs Canada.
As the client or the client's legal representative: I understand it is against the law to knowingly make a false or misleading statement; as legal representative I declare the client to be alive; I agree to notify VAC of any changes affecting eligibility; I have read and understand the Privacy Notice; and I declare the information is true and complete, with the same force and effect as if made under oath.
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As the client or the client's legal representative: I understand it is against the law to knowingly make a false or misleading statement; as legal representative I declare the client to be alive; I agree to notify VAC of any changes affecting eligibility; I have read and understand the Privacy Notice; and I declare the information is true and complete, with the same force and effect as if made under oath.
Signature
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Date (yyyy-mm-dd)
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Month
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Day
Year
Date
Submit
Submit
Should be Empty: