Request for verification: Release of personal census data

This form applies only to censuses taken in 2006, 2011 and 2016. The information entered on this form cannot be submitted online. It must be printed and returned by mail to Statistics Canada using the address below.

I would like to verify my response to the consent question on the Census of Population questionnaire for the census year:

Note: A separate form is required for each member of the household who wishes to verify his or her response to the consent question for the census year specified above.

Please provide the following information for the person requesting verification:

1. Name
2. Current mailing address
3. Address in May of census year specified above
4. Date of birth (required for validation purposes only) (YYYY-MM-DD)
5. Current telephone number
6. Signature of applicant*
*If the person requesting a verification is currently under the age of 16, a parent or legal guardian must sign in his or her place. In all other cases, only the person authorizing a verification of response may sign.
7. Date

Return the completed form by mail to:

Departmental Privacy Officer
Statistics Canada
2nd Floor, R.H. Coats Building
100 Tunney's Pasture Driveway
Ottawa, Ontario
K1A 0T6
Date modified: