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CPT17 (01)

Canada Customs and Revenue Agency

APPLICATION FOR CERTIFICATION OF A RELIGIOUS SECT SEEKING EXEMPTION FROM 
COVERAGE UNDER THE CANADA PENSION PLAN

- For use by the authorized spokesperson of a religious sect which has 
qualified for exemption and whose members may wish to apply for exemption from 
coverage under the Canada Pension Plan on Account of Religious Beliefs.

- Two completed copies of this application are to be forwarded to Canada 
Customs and Revenue Agency, 875 Heron Road, Ottawa Ontario K1A OL8, Attention: 
CPP/EI Eligibility Division.

- A copy of documentary evidence in support of the statements below must be 
attached.

Name of Religious Sect (Print) ^
Number of Members in Sect ^
Mailing Address ^

Statement of Authorized Spokesperson

I am (Title or Position) ^
duly authorized spokesperson for the religious sect named above and certify 
the following information regarding this religious sect:

(a) the established tenets and teachings of this religious sect oppose the 
acceptance of benefits of any private or public insurance which makes payments 
in the event of death, disability, old age or retirement,

(b) the religious sect does, as a practice, make provision for its dependent 
members which is reasonable in view of their general level of living, and

(c) the religious sect was in existence in Canada on January 1, 1966 and has 
maintained the beliefs stated in (a) and (b) since that date.

Date ^
Signature of Authorized Spokesperson ^

FOR CANADA CUSTOMS AND REVENUE AGENCY USE ONLY
Approved By
Date (Year/Month/Day)
Registration Number