Family Connections
Declaration Form
Section 1: Personal Information
This section includes information about the PEI resident who is requesting family connections.
Name: First: Last:
City Town: Province:
Phone: Postal Code:
Email address (required):
Section 2: List of all persons living at the above residence in PEI (add additional page if required)
1. First: Last: Signature:
2. First: Last: Signature:
3. First: Last: Signature:
4. First: Last: Signature:
5. First: Last: Signature:
Section 3: PEI Residency
PEI residents are asked to provide proof of residency and these are the accepted pieces of documentation:
Valid Prince Edward Island driver’s license or Prince Edward Island voluntary identication card containing the person’s address of
principal residence on Prince Edward Island,
plus any one of the following:
• Valid PEI Health card;
• Valid PEI Motor vehicle registration certicate; or
• 2018 or 2019 Canada Revenue Agency (“CRA”) Notice of Assessment identifying Prince Edward Island as their Province of
residency (see line 428 of Notice indicating jurisdiction of taxation).
If a person does NOT possess a valid Prince Edward Island driver’s license or voluntary identication card, they must present:
a valid driver’s license or government-issued photo identication card from another jurisdiction;
plus any two of the following:
• Valid PEI health card;
• Valid PEI motor vehicle registration certicate; or
• 2018 or 2019 CRA Notice of Assessment identifying Prince Edward Island as their Province of residency
(see line 428 of Notice indicating jurisdiction of taxation).
Section 4: Declaration
By signature of this document, I, as the PEI resident, make the following declarations:
• I am 18 years of age or older.
• I am a Canadian citizen or permanent resident residing in PEI.
• The Family Connections are my family member(s), which is dened as parent, child, sibling, grandchild, grandparent, or
signicant other.
• I understand that the Family Connections must self-isolate for a period of 14 days upon arrival.
• I declare that the information given on this form is complete, correct and fully discloses everything concerning my eligibility
to have the Family Connections travel to PEI.
• I understand that it is an oence to knowingly provide false or misleading information, either orally or in writing, to a public
health ocial under the Public Health Act for which I may be ticketed $1,000 per occurrence.
Name of Person requesting Family Connections:
Signature: Date:
Emergency Measures Organization Use Only
Date received:
Received by name and signature:
DG-205
