Ministère de l’Immigration et des Communautés culturelles A-0522-OA (2013-01)

CONTRACT RESPECTING FINANCIAL SELF-SUFFICIENCYPrincipal Applicant (excluding live-in caregivers and persons authorized to apply for permanentresidence in Canada on humanitarian grounds)

INSTRUCTIONS

Who must fill out this form

The principal applicant (including a foreign student or foreign worker living temporarily in Québec) and his or her accompanying spouse or defacto spouse, if any, who applies for a Certificat de sélection du Québec (Quebec selection certificate) under the subclass of Skilled Workers,Entrepreneurs or Self-Employed Persons.

If you are a live-in caregiver or if you are authorized by Citizenship and Immigration Canada to apply for permanent residence in Canada onhumanitarian grounds, this form is not intended for you. You must instead fill out the form entitled Contract respecting financial self-sufficiency– Live-in caregiver and person authorized to apply for permanent residence in Canada on humanitarian grounds.

What is the Contract respecting financial self-sufficiency

The Contract respecting financial self-sufficiency is a legal act by which you undertake, for the entire term of the contract, to provide for yourbasic needs and, where applicable, those of your spouse or de facto spouse and your dependent children (including those who are Canadiancitizens) who accompany you to Québec. The term of the contract is three months starting on the date of your arrival in Québec as a permanentresident. Basic needs include food, clothing, personal necessities and housing-related expenses.

You must sign this contract or else your application for a selection certificate will not be accepted. For more information, see the Actrespecting immigration to Québec (R.S.Q., c. I-0.2) and the Regulation respecting the selection of foreign nationals (R.R.Q. 1981, c. M-23.1, r. 2).

How to fill out this form

Section A identifies you and, where applicable, your spouse or de facto spouse and dependent children (including Canadian citizens) who areaccompanying you. Answer the questions accurately.

Section B of the contract. Read the contract carefully and sign it. Don't forget to enter, at Point 1, the amount at your disposal when youarrive in Québec to support your needs and, where applicable, the needs of your spouse or de facto spouse and of your dependentchildren. To learn the minimum amount required in your situation, use the calculation table below (use the greyed spaces to enter the amountsthat apply to your situation and to calculate your minimum required amount).

TABLE FOR CALCULATING THE MINIMUM AMOUNT REQUIRED FOR THE ESSENTIAL NEEDS OF PRINCIPAL FAMILY UNITSFOR THE THREE-MONTH PERIOD FOLLOWING ARRIVAL IN QUÉBEC (AMOUNTS IN EFFECT FROM JANUARY 1 TO DECEMBER 31, 2013)

Examples of calculations based on accompanying persons:- Principal applicant with spouse and 2 children under 18 years old = $5,185- Principal applicant with spouse and one child under 18 years old and one child age 18 or older = $4,804 + $1,364 $ = $6,168- Principal applicant with spouse and four children under 18 years old = $5,566 + $381 = $5 947- Principal applicant without spouse but with one child under 18 years old and 2 children age 18 or older = $3,930 + (2 X $1,364) = $6,658

Under 18years old

18 yearsor older

0

1

2

3

State the number ofadditional children:

State the numberof children:

$2,924

$3,930

$4,436

$4,942

Add $506 peradditional child

Add $1,364per child

Add $381 peradditional child

Minimumrequired $

Add $1,364per child

$4,288

$4,804

$5,185

$5,566

Principal applicantwithout spouse or

accompanying spouse

Number of accompanying dependent children(including ones who are Canadian citizens)

Principal applicantwith accompanying

spouse

Calculation of minimumamount required for your

basic needs

Ministère de l’Immigration et des Communautés culturelles A-0522-OA (2013-01)Page 1 of 2

Section AIDENTIFICATION OF THE PRINCIPAL APPLICANT

IDENTIFICATION OF ACCOMPANYING SPOUSE ORDE FACTO SPOUSE AND DEPENDENT CHILDREN

Family name at birth: ____________________________________________________________ First name: ____________________________________________________

Family name after marriage (where applicable) : ______________________________________ Sex: F M Date of birth: ____________________________

Marital status: Single Married De facto spouse Separated Divorced Marriage annulled Widowed

Residence address: ________________________________________________________________________________________________________________________________

______________________________________________________________________________________________

______________________________________________________ Telephone number: ______________________________________________

Year / Month / Day

Family Name(at birth) FIRST NAME SEX

DATE OFBIRTH

Year / Month / Day

ADDRESS(if different from the principal applicant)

A - Spouse or de facto spouse

1

2

3

4

5

6

B - Dependent children (including children who are Canadian citizens)

CONTRACT RESPECTING FINANCIAL SELF-SUFFICIENCYPrincipal Applicant (excluding live-in caregivers and persons authorized to apply for permanentresidence in Canada on humanitarian grounds)

Reserved for Administration

Individual Reference No. :

File No. :

I acknowledge having read the information on this form and I understand the nature and scope of the contract respecting financial self-sufficiency. Consequently:

1. I declare that, for the term of this contract, which is three months from the date of my arrival in Québec as a permanent resident, I will have financial resourcesat least equal to the amount prescribed in Appendix C of the Regulation respecting the selection of foreign nationals, adjusted for 3 months, to meet basic needs,specifically an amount of CA $ _______________________ .

2. I undertake to provide for my basic needs and those of other persons identified in Section A for the full term of the contract.

3. I undertake to reimburse the Government of Québec for any amount that it may pay me or other persons identified in Section A, in the form of last resort financialassistance, in accordance with applicable legislation, throughout the full term of the contract.

4. I authorize the Ministère de l'Immigration et des Communautés culturelles to transmit information about this contract to the Ministère de l'Emploi et de la Solidaritésociale, if any application is made for last resort financial assistance for myself or for any persons identified in Section A.

5. If I belong to the Skilled Worker subclass, I acknowledge having been informed that the Ministère, after examining my situation and that of my spouse or de factospouse, may choose to change the principal applicant if the situation is more advantageous for the award of points in the selection grid. In this case, only theperson among us who will be the principal applicant will be bound by the commitments mentioned above.

In witness whereof, I have signed at ___________________________________________________________ on ____________________________

__________________________________________________________________________________________________________________

In witness whereof, I have signed at ___________________________________________________________ on ____________________________

_____________________________________________________________________________________________________________________________

Section BCONTRACT

Year / Month / DayCity

Year / Month / DayCity

Signature of the principal applicant

Signature of the spouse or de facto spouse (signature required only if he or she is accompanying a principal applicant in the Skilled Worker subclass)

A-0522-OA (2013-01)Page 2 of 2

Please keep a signed copy of this form and return the other signed copywith your application for a Quebec selection certificate.