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Authorization for the collection and A-0527-FO

communication of personal information (2018-10)

reserved for administration

NOToindividual reference

NOToof the folder

Note: To simplify the text, the terms and expressions used include both grammatical genres.

You must complete and sign this form if you have ever been separated or divorced or if you have children from a previous union.

Read the provisions relating to this authorization carefully. Be advised that a refusal to sign will result in the refusal of your request.

Authorization

For the purposes of administering the commitment request, I authorize Revenu Québec to communicate to the Ministry of Immigration, Diversity and
Inclusion (MIDI) the information provided for herein, making it possible to determine whether:
1. I am currently in default1relating to the payment of alimony for the benefit of my spouse or ex-spouse or my child
and,
if yes,
2. I have been the subject of an appeal2for non-payment of alimony to my spouse or ex-spouse or my child, during the five years
preceding the date of this authorization;
3. I have entered into an agreement regarding the reimbursement of amounts owed and allowing the expiry date of this agreement to be indicated.

Last name at birth (printed letters) First name (printed letters)

Date of birth (year/month/day) social security number

Number street Apartment

City Province Postcode

Signature of guarantor or co-signing spouse Date (year/month/day)

RESERVED FOR THE QUEBEC REVENUE ADMINISTRATION

1. The guarantor, or co-guarantor mentioned above, is currently in default1relating to the

payment of alimony for the benefit of his spouse or ex-spouse or his child. Yes No
If yes,

2. The guarantor, or co-guarantor has been the subject of an appeal2for non-payment of alimony to one's
spouse or ex-spouse or child during the five years preceding the Yes No
(year, month, day)

3. An agreement concerning the reimbursement of the amounts owed has been concluded between Revenu Québec and the
guarantor or co-guarantor. Yes No
It is expected that the amounts due will be reimbursed in full on
(year, month, day)

Name and first name of the Revenu Québec agent (printed letters) Phone number

Signature of the Revenu Québec agent Date (year/month/day)

1. The guarantor is no longer considered in default when the sums due following an appeal, as described in the following note, have been reimbursedIn totality.

2. Forced execution measure following a court judgment ordering the payment of alimony or recourse, procedure, or forceful execution measure referred to in article 47 of the Act
facilitating the payment of alimony alimony (RSQ, c. P-2.2) or recovery measure referred to in sections 48, 49, 50 or 53 of this law.

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Imprimer Effacer
Ministry of Immigration, Diversity and Inclusion A-0527-FO (2018-10)