RPD.24.01 (July 31, 2018)
Disponible en français
RPD File: _________________________
UCI: _________________________
NOTICE OF WITHDRAWAL OF A CLAIM FOR REFUGEE PROTECTION
[Refugee Protection Division Rules, subrule 59(2)]
Instructions: please complete a separate form for each claimant.
In the claim for refugee protection of:
I, _______________________________________, am withdrawing my claim for refugee protection.
I am freely withdrawing my claim for refugee protection, and I am fully aware of the consequences of
this withdrawal. I am aware that as a result of the withdrawal of my claim, the Canada Border Services
Agency may require me to leave Canada, and I will not be permitted to make another claim for refugee
protection in Canada.
Claimant’s Signature: _______________________________ Date: ____________________
Claimant’s addr
ess: ________________________________________________________________
___________________________________________________ Phone: (____)__________________
Obtain Confirmation of Withdrawal:
by mail
pick-up at reception
Claimant’s Declaration
I declare that I am able to read English and that I fully understand the entire content of this notice in
English.
Claimant’s Signature: _______________________________ Date: ____________________
Or
Interpreter’s Declaration
I (please print clearly), _____________________________, certify that I have accurately translated the
entire content of this form for the claimant from the English language to the_____________________
language. The claimant indicated that he/she fully understands the entire content of this notice as
translated.
Interpreter’s Signature: _______________________________ Date: ____________________
Note
Under subrule 59(3) of the Refugee Protection Division Rules, if you want to withdraw your claim for refugee protection
but you already attended your hearing, you must make a written application to the RPD under rule 50. In that case, you may
not use this form.
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