Complete a Residency Statutory Declaration

Complete a Residency Statutory Declaration if you cannot provide standard proof of NWT residency or if you are away from the territory for an extended period. This page explains when you need this declaration, what it includes and how to submit it with the correct form.

You may need this declaration if you:

• Recently moved to the NWT and cannot provide two residency documents, or
• Are leaving the NWT for a long winter vacation or extended absence and must confirm that the NWT remains your primary residence

Complete this declaration only when it is required to support:

• An NWT Application for Health Care, or
• A Temporary Absence Form

There are no prerequisites for completing the declaration.

You will need:

• Your full name, date of birth and NWT home address
• A statement confirming one of the following: 
  • You moved to the NWT and will live here for more than 12 months, or
  • The NWT is your primary residence and you were physically present at least 153 days this calendar year
• A Commissioner for Oaths, Notary Public, Justice of the Peace or RCMP to witness and sign the declaration

If you are submitting this with an application for health care or a temporary absence, gather those forms as well.

Keep copies of your declaration and all documents you submit.

1. Download the Residency Statutory Declaration.
2. Complete every section of the form, including your personal information and your residency statement.
3. Sign the form in front of a Commissioner for Oaths, Notary Public, Justice of the Peace or RCMP member.
4. Attach the declaration to your NWT Application for Health Care or Temporary Absence Form.
5. Submit your completed forms by email, mail or fax to the Health Services Administration Office.
6. Keep a copy of your declaration and documents for your records.

There is no fee to submit a residency declaration.

The Health Services Administration Office reviews your declaration and the form it supports.

You may be contacted if more information is needed.

Your residency will be confirmed once all required information is verified.