Common-Law Spouse Benefits and Privileges

COMMON-LAW SPOUSE BENEFITS AND PRIVILEGES

STATUTORY DECLARATION - Pursuant to Section 38 of the Canada Evidence Act

1, (Employee No. ), an employee of Canadian (employee name in full) North (the “Company”), solemnly declare that:

(1) This declaration is in support of my application for enrollment as a dependent on my benefit plans and for free or reduced rate travel privileges (collectively, the “benefits and privileges”) of , (the “Spouse”), whose birth date is (Spouse’s name in full) , and whose marital status is (day/month/year) (single/divorced/separated/widowed)

Cohabitation commenced on:

My marital status is: (single/divorced/separated/widowed)

(2) I have been residing continuously with the Spouse for a period of:

(Please indicate with an X in the applicable box.)

(a) At least three (3) continuous years and by law we are prohibited from marrying by reason of a marriage of one of us to another person and throughout this period my partner has been publicly represented as my spouse.

- or -

(b) At least 12 continuous months and throughout this period my partner has been publicly represented as my spouse and neither of us is married to another person.

During this period, we have maintained one common residence at the following address(es). If more than one address, state effective dates: Address: Address:

From: From: To: To:

(3) I understand and agree that, subject to conditions in reduced rate interline agreements with other air carriers, transportation is on aircraft operated by the Company only, and that upon request the Spouse and/or I will produce proof of identification bearing the name(s) endorsed/printed on any and all travel passes/tickets which shall include our signatures.

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(4) If I cease to continuously reside with the Spouse and/or we cease to be publicly represented as husband and wife, I understand and agree that I will notify my direct report in writing within 30 days, in order to cancel the benefits and privileges that may have been extended to the Spouse and his/her children.

(5) I understand and agree that the Company will not in any manner be held responsible in the event of any personal and/or legal problems or disputes arising out of the benefits and privileges accorded to the Spouse and his/her children, and I further agree to indemnify and hold harmless the Company from and against any claims, liabilities, damages and costs whatsoever arising from such problems and disputes.

(6) I understand and agree that in the event this Declaration is proven to the satisfaction of the Company to be false, the benefits and privileges that may have been granted to the Spouse and his/her children will immediately terminate and I hereby agree to make full restitution to the Company in respect of such fraudulently obtained benefits and privileges. I further understand that I will be subject to disciplinary action up to and including termination of my employment in the event of the above.

(7) I understand that any person who knowingly and willfully assists in obtaining free or reduced rate transportation not lawfully in accordance with the Issuance of Free and Reduced Rate Transportation Letter of the Air Transport Committee, dated March 21, 1986, and appendages thereto, and any orders or regulations pursuant to the National Transportation Act, may be subject to a penalty for each offence, and in addition, that I shall be required in such instance to reimburse the Company the amount which would otherwise have had to be paid and that I may be subject to disciplinary action including termination of my employment with the Company.

(8) I understand and agree that in the event I am legally married at the date of this Declaration, any benefits and privileges to which my legal spouse may be entitled will terminate as of the date the Spouse becomes entitled to receive such benefits and privileges.

I have read and understood the foregoing statements and I make this solemn declaration conscientiously believing it to be true and knowing that it is of the same legal force and effect as if made under oath.

Declared before me at the City of ) in the Province of ) this Day of 20 ) ) ) Employee’s Signature ) ) ) ) Employee’s Name (please print) ) A Notary Public/Commissioner for Oaths in and for ) the Province of ) Commission expires ) (stamp or seal must accompany signature) ) Date (dd/mm/yy)

PLEASE FORWARD COMPLETED DOCUMENT BY COMPANY MAIL TO PAYROLL (YZFOO5T).