Citizenship and Citoyenneté et PROTECTED WHEN COMPLETED - B

Immigration Canada Immigration Canada

PAGE 1 OF 2

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
Date of birth Present address Will
Relationship Y M D (If deceased give city and date) accompany
Full name Marital status
SEE NOTE 1 Country you to Canada?
Present occupation
of birth YES NO

Anshuman Mathur Single 286 6th block 18th d main koramangala Bangalore 560095
1981 10 06
APPLICANT
India
Digital Marketing Manager

SPOUSE OR
COMMON-LAW
PARTNER

Deepa Mathur 286 6th block 18th d main koramangala Bangalore 560095
1955 07 13
MOTHER
India
✔
Home Maker

Deepak Mathur 286 6th block 18th d main koramangala Bangalore 560095
1950 01 02
FATHER
India
✔
General Manager

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

I certify that I do not have a spouse or a common-law partner. Signature: Date: 2017 04 03

SECTION B CHILDREN (Include ALL sons and daughters, including ALL adopted and step-children, regardless of age or place of residence)
Date of birth Present address Will
Relationship Y M D (If deceased give city and date) accompany
Full name Marital status
SEE NOTE 2 Country you to Canada?
Present occupation
of birth YES NO

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

Year Month Day

I certify that I do not have any children, either natural or adopted. Signature: Date: 2012 04 03

IMM 5645 (09-2010) 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.)
Date of birth Present address Will
Y M D (If deceased give city and date) accompany
Full name Relationship Marital status
Country you to Canada?
Present occupation
of birth YES NO

Dipti Mathur Sister Married flat 27 1 Hansel road London

1977 12 07
✔
Investment Banker

SECTION D CERTIFICATION
I certify that the information contained on 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.

Year Month Day

Signature: Date: 2017 04 03

The information you provide on this form is collected under the authority of the Immigration and Refugee Protection Act to determine if you may be admitted to Canada as a temporary
resident. It will be stored in Personal Information Bank CIC PPU 055, Visitor Case File. It is protected and accessible under the Privacy Act and the Access to Information Act.

IMM 5645 (09-2010) E