Request for change: 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 authorize Statistics Canada to change my response to the consent question on the Census of Population questionnaire for the census year:

2006 2011 2016

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

Please provide the following information for the person requesting the change:

1. Name

First Name Last Name

2. Current mailing address

Address (unit, number, street) City Province/territory Postal code

3. Address in May of census year specified above

Address (unit, number, street) City Province/territory Postal code

4. Date of birth (required for validation purposes only) (YYYY-MM-DD)

Date of birth

5. Current telephone number

Telephone number

6. Requested change (check applicable option)

I agree to make my Census of Population information available for public release 92 years after the census year specified above. I do not agree to make my Census of Population information available for public release 92 years after the census year specified above.

7. Signature of applicant*

Signature

*If the person authorizing a change of response is currently under the age of 16, a parent or legal guardian may sign in his or her place. In all other cases, only the person authorizing a change of response may sign.

8. Date

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:: 2017-01-13

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Request for change: Release of personal census data