Statutory Declaration – By Intended Parents

Vital Statistics Act

In the matter of the birth of:

,
(Child’s Last or Single Name) (Child’s First and Middle Names)
born on at
(yyyy/mm/dd) (Name of City, Town or Village)

I/We ,
(Legal name of intended parent) (Legal name of intended parent)

,
(Legal name of intended parent) (Legal name of intended parent)

hereby declare that I/we entered into a written surrogacy agreement with

,
(Surrogate’s Last or Single Name) (Surrogate’s First and Middle Names)
on .
(yyyy/mm/dd)

I/We further declare the following:

1. The surrogacy agreement that I/we entered into with the surrogate was made prior to the conception of the child born on
.
(yyyy/mm/dd)
2. I/We received independent legal advice1 before entering into the surrogacy agreement;
3. The child was conceived through assisted reproduction2;
4. I/We have complied with all relevant surrogacy requirements in the Children’s Law Reform Act and the Vital Statistics Act;
5. I/We agree that each intended parent is recognized in law to be a parent of the child; and,
6. I/We agree that the surrogate’s consent to relinquish any and all entitlement to parentage of the child was not provided until
at least seven days after the birth of the child.

I/We 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.

Declared before me in the City of in the province of Ontario,

(Name of City, Town or Village)
on this day of , 20 .
day month

Signature of Intended Parent Signature of Intended Parent

Signature of Intended Parent Signature of Intended Parent

(A Commissioner, etc.) (Sign, print name and affix commissioner’s stamp or describe office, if stamp not required)

1 “Independent legal advice”: A lawyer who is independent (not acting for the surrogate or other intended parents) must provide advice about
the legal consequences of entering into a surrogacy agreement.
2 “Assisted reproduction”: a method of conceiving other than by sexual intercourse

Personal information contained on this form is collected under the authority of the Vital Statistics Act, R.S.O. 1990, c.V.4 and may be used to
register and record births, provide certified copies, extracts, certificates, search notices, and for statistical, research, medical, law enforcement,
adoption and adoption disclosure purposes as applicable. It is an offence to wilfully make a false statement on this form. It is an offence to
certify the form on behalf of another person. Questions about this collection should be directed to: The Deputy Registrar General, Office of the
Registrar General, 189 Red River Road, PO Box 4600, Thunder Bay ON P7B 6L8. Telephone: 1-800-461-2156 or 416-325-8305, TTY/
Teletypewriter (for the hearing impaired): 1-800-268-7095 or 416-325-3408.

11333E (2022/11) © King's Printer for Ontario, 2022 Disponible en français

Print Form Clear Form