PROTECTED WHEN COMPLETED - B

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FAMILY INFORMATION
Type of application: ✔ Visitor Worker Student Other

Complete ALL names in English and in your native language (for example, Arabic, Cyrillic, Chinese, Chinese commercial/telegraphic code, Korean, or
Japanese characters). Include ALL family members even if they are not accompanying you. If you need more space for any section, print out an additional
page containing the appropriate section, complete and submit it with your application.

BEFORE YOU START, READ THE INSTRUCTION GUIDE, TYPE OR PRINT IN BLACK INK.
SECTION A
Will accompany
Relationship Date of birth Present address
Name you to Canada?
SEE NOTE 1 (YYYY-MM-DD) (if deceased: give city/town, country and date)
YES NO

Tuti Sriningsih 1966-01-04 Taman Kopo Indah I Blok E No. 92, Bandung
Applicant Country of birth:
Marital status: Indonesia Present occupation:
Widowed
Marketing self employed / contractor
Hardi Sugityo (deceased) Jakarta, Indonesia - deceased August 1998
Spouse or
common-law Country of birth:
Marital status: partner Indonesia Present occupation:
Annulled marriage

Sulistiowati 1936-12-07

Mother Country of birth: ✔

Marital status: Indonesia Present occupation:
Retired
Edy Santoso (deceased) 1934-03-20 Bandung, Indonesia - deceased Oktober 2018
Father Country of birth: ✔
Marital status: Indonesia Present occupation:

NOTE 1: If no spouse or common-law partner is listed in Section A, read and sign below.

I certify that I do not have a spouse or a common-law partner.

Signature: Date (YYYY-MM-DD)

SECTION B - CHILDREN (Include ALL sons and daughters, including ALL adopted and step-children, regardless of age or place of residence)
Will accompany
Relationship Date of birth Present address
Name you to Canada?
SEE NOTE 2 (YYYY-MM-DD) (if deceased: give city/town, country and date)
YES NO

Chintami Padmadawala Biologica 1990-01-11 148 Huntstrom DR NE, Calgary AB T2K 5V8 CA
l Country of birth: ✔
Marital status: Daughter Indonesia Present occupation:
Married
Business Systems Analyst
Gideon Chang Biologica 1994-06-10 70 Ghent St, St. Catharines ON L2N 2C9 CA
l Son Country of birth: ✔
Marital status: Indonesia Present occupation:
Married
Bartender and construction worker

Country of birth:
Marital status: Present occupation:

Country of birth:
Marital status: Present occupation:

NOTE 2: If no children are listed in Section B, read and sign below.

I certify that I do not have any natural, adopted nor step-children.

Signature: Date (YYYY-MM-DD)

IMM 5645 (01-2021) E (DISPONIBLE EN FRANÇAIS - IMM 5645 F)

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SECTION C - BROTHERS AND SISTERS (Include ALL brothers and sisters, ALL half-brother and sister and stepbrother and sister.)
Will accompany
Relationship Date of birth Present address
Name you to Canada?
SEE NOTE 2 (YYYY-MM-DD) (if deceased: give city/town, country and date)
YES NO

Dr Anik Widajati Sister 1956-06-20 Taman ratu blok A1 No.19 Jakarta, Indonesia
Country of birth: ✔
Marital status: Indonesia Present occupation:
Married
Doctor
Endang Sukarsih Sister 1957-11-05 Jurang 67 Bandung, Indonesia
Country of birth: ✔
Marital status: Indonesia Present occupation:
Married
Self Employed
Ritawati Sister 1960-10-02 Kebon Raya 35 Jakarta, Indonesia
Country of birth: ✔
Marital status: Indonesia Present occupation:
Married
Self Employed
Mariana Sister 1961-09-16 Cluster Malibu, Decker 31 Tangerang,
Country of birth: Indonesia ✔
Marital status: Indonesia Present occupation:
Married
Self Employed
Djoko Susanto Brohter 1967-04-17 Batununggal Indah Raya 173 Bandung,
Country of birth: Indonesia ✔
Marital status: Indonesia Present occupation:
Married
Restaurant Owner
Ernawati Sister 1968-08-18 1237 N Council ave. Ontario Ca 91764
Country of birth: ✔
Marital status: Indonesia Present occupation:
Married
Care Giver
Dicki Susanto Brother 1971-11-26 Babakan Jeruk IIIF 12 Bandung, Indonesia
Country of birth: ✔
Marital status: Indonesia Present occupation:
Married
Self Employed
SECTION D - CERTIFICATION

I certify that the information contained in this document is complete, accurate and factual. I also realize that once this document has been completed and signed that it
will form part of my Immigration Record and will be used to verify my family details on future applications.

Signature: Date (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 provided 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, foreign governments for the purpose of validating identity, eligibility and admissibility. The
personal information may also be disclosed to medical practitioners for the purpose of validating identity and eligibility.

Personal information may also be used for other purposes including research, statistics, program and policy evaluation, internal audit, compliance, risk management, subsequent
program eligibility, and 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 013, 051, 068.

IMM 5645 (01-2021) E