PROTECTED WHEN COMPLETED - B

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VERIFICATION OF STATUS (VOS) OR REPLACEMENT OF AN IMMIGRATION DOCUMENT

(To be completed and returned with the application checklist)
1 Client ID number/UCI
PART A - PERSONAL DETAILS
2 Surname (Family name) on entry 3 Given name(s) on entry

4 Current surname (if different from name on entry) 5 Current given name (if different from name on entry)

6 Gender 7 Date of 8 Place of birth (City, state/province and country or territory) 9 Citizenship
F Female M Male X Another gender birth YYYY-MM-DD
10 Passport number Indicate if: 11 Date of 12 Expiry
On entry Current issue YYYY-MM-DD date YYYY-MM-DD
13 Marital status on entry
If you are married, is your spouse a
Never married Married Yes No
Canadian citizen or permanent resident?

Widowed Separated Divorced Common-law partner

14
Language of correspondence English French

15 Current mailing address

P.O. box Apt./Unit Street no. Street name

City/Town Country or territory Province/State Postal code District

16 Residential address Same as mailing address?

No Yes

Apt./Unit Street no. Street name City/Town

Country or territory Province/State Postal code District

17 18
Telephone no. Canada/US Other Alternate Telephone no. Canada/US Other

Type Country Code No. Ext. Type Country Code No. Ext.

19 E-mail address: (Indicating an e-mail address will authorize all correspondence, including file and personal information, to be sent to the e-mail address you specify.)

PART B - DOCUMENTS REQUESTED

1 What type of request

Verification of Status Replacement of a valid temporary resident document
are you making?
2 Immigration document 3 Canadian port of entry - Place of issue
Date of Issue YYYY-MM-DD
4 Indicate for which of the following you need a replacement copy or a Verification of Status document. If you have more than one valid temporary resident document,
indicate the document ID number or if unknown, the document issue and expiry date of the requested document.

Immigrant Visa and Record of Landing -

Exclusion Order Departure Order
Confirmation of Permanent Residence
Permit to Come Into or Remain in Canada -
Authorization to Return to Canada Protected Person
Temporary Resident Permit
OR Issue date: and Expiry date:
Work Permit ID No.: (YYYY-MM-DD) (YYYY-MM-DD)

OR Issue date: and Expiry date:

Study Permit ID No.: (YYYY-MM-DD) (YYYY-MM-DD)

OR Issue date: and Expiry date:

Visitor Record ID No.: (YYYY-MM-DD) (YYYY-MM-DD)

This form is made available by Immigration, Refugees and Citizenship Canada and is not to be sold to applicants.

IMM 5009 (01-2023) E (DISPONIBLE EN FRANÇAIS - IMM 5009 F)

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PART B - DOCUMENTS REQUESTED (continued)

5 Was your original
immigration document Lost Stolen Destroyed Other
Provide details. If the document was a valid temporary resident document and was lost or stolen, indicate the police report number. If you do not have a police report number,
please provide a brief explanation in the space provided.

6 If you are requesting a Verification of Status of an Immigrant Visa and Record of Landing/Confirmation of Permanent Residence have you applied for it before?

No Yes If yes, when did you apply?

YYYY-MM-DD

7 If you are applying for a Verification of Status of an Immigrant Visa and Record of Landing/Confirmation of Permanent Residence and you are not a Canadian citizen,
have you, since your admission to Canada as a permanent resident, been convicted of a crime or offence in Canada or elsewhere?

No Yes If yes, attach copies of the relevant court documents.

8
Are you a Canadian citizen? No Yes

9 List all names you have ever used.

Surname (Family name) Given name(s) Other name(s)

(Middle name, maiden name, alias, initials, etc.)

10
Did you enter Canada as a Visitor Student Worker Permanent Resident Protected Person

PART C - IF YOU ENTERED CANADA AS A PERMANENT RESIDENT PRIOR TO 1973, COMPLETE THE FOLLOWING SECTION
1 Provide the full names and date of birth of the person(s) who accompanied you on arrival in Canada.
(e.g., middle name, maiden name, English name or alias.)

Other name(s)
Surname (Family name) Given name(s) Date of birth
(Middle name, maiden name, alias, initials, etc.)
YYYY-MM-DD

2
Were either of your parents born Canadian citizens? No Yes

3 What are the names and dates of birth of your parents?

Other name(s)
Surname (Family name) Given name(s) Date of birth
(Middle name, maiden name, alias, initials, etc.)
YYYY-MM-DD

IMM 5009 (01-2023) E

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4 What is/was the occupation of each of your parents?

Mother's occupation

Father's occupation

5
Had you or your parents ever been part of any military at the time you entered Canada? No Yes

DECLARATION
I solemnly declare that the information I have provided is, to the best of my knowledge, complete and accurate. I authorize the department of Immigration, Refugees and
Citizenship Canada to verify the information I have provided. If I am requesting a replacement document and should I ever regain possession of the original document, I
promise to return it immediately to Immigration, Refugees and Citizenship Canada.

Signature Date
YYYY-MM-DD

Signature Date
parent/legal guardian (if applicant is under 18)
YYYY-MM-DD

Personal information provided on this form is collected by Immigration, Refugees, and Citizenship Canada (IRCC) under the authority of the Immigration and Refugee Protection
Act (IRPA). The personal information will be used for the purpose of processing an application. The personal information provided may be disclosed to other federal government
institutions, law enforcement bodies, provincial/territorial governments and foreign governments for the purpose of validating identity, admissibility and eligibility.

Personal information may also be used for other purposes including research, statistics, program and policy evaluation, internal audit, risk management, subsequent program
eligibility, strategy development and reporting.

Failure to complete the form in full may result in a delay or the application not being processed. The Privacy Act gives individuals the right of access to, protection, and correction
of their personal information. If you are not satisfied with the manner in which IRCC handles your personal information, you may exercise your right to file a complaint to the Office
of the Privacy Commissioner of Canada. The collection, use, disclosure and retention of your personal information is further described in IRCC’s Personal Information Bank –
IRCC PPU 068.

IMM 5009 (01-2023) E

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DOCUMENT CHECKLIST
VERIFICATION OF STATUS (VOS) OR REPLACEMENT OF AN IMMIGRATION DOCUMENT

Ensure the following documents are included with your application. Check R each box once you enclose the item. Failure to provide a
fully completed application or the necessary documents will result in the return of your application. Please make sure you complete
this document and include it with your application as the cover page. Submit photocopies of documents unless we ask for originals as
they will not be returned to you.
I HAVE ENCLOSED THE FOLLOWING ITEMS:

Original application form Verification of Status (VoS) or Replacement of an Immigration Document (IMM 5009) completed and signed.

Photocopy of one piece of federal or provincial/territorial government issued photo identification OR if unavailable, photocopy of
government issued photo identification from outside Canada. (See "Gather Documents" section in the Instruction guide for examples.)

Photocopy of another form of identification issued by the federal or provincial/territorial government of Canada or if unavailable, a
photocopy of government issued identification from outside Canada. (See "Gather Documents" section in the Instruction guide for
examples.)

Photocopy of court documents if you have been convicted of a crime since becoming a permanent resident (if you are not a Canadian
citizen).

Copy of the fee receipt showing the amount paid. (See "Pay the Fees" section in the Instruction guide for the correct VoS fee)

Original Use of a Representative (IMM 5476) form completed and signed, if applicable.

Proof of urgency, if applicable.

REQUEST ON BEHALF OF A DECEASED PERSON

Proof of death, OR

Proof that you are the lawful executor or administrator of the estate. If the person is deceased less than 20 years, only the lawful
executor or administrator of the estate may request the personal information.
• One piece of federal or provincial/territorial government issued photo identification of the lawful executor or administrator of the
estate.

IMM 5009 (01-2023) E