Service PROTECTED B (when completed)

Canada
CDN - USA 1
Application for Canadian Old Age, Retirement and Survivors
benefits under the Agreement on Social Security between
Canada and the United States
In which language do you wish to receive your correspondence? - Read the enclosed guide
Please:
English French - Complete the unshaded areas only
SECTION 1 - TO BE COMPLETED BY ALL APPLICANTS For use by the Social
Security Institution
1. Social Security Numbers of the contributor or applicant for an Old Age Security Pension of the United States
U.S. Social Security Number Canadian Social Insurance Number only

Date of receipt:
2. Indicate the benefits for which you wish to apply and submit the required documentation.
A. BENEFIT BASED ON RESIDENCE IN CANADA AFTER REACHING AGE 18:
Old Age Security Pension
Complete: Sections 1, 2, 3 and 7
Verified by:
Submit: Indicate: Year Month Day
- a birth certificate - date of birth
- proof of the legal status of your residence in Canada at the time of your departure
(Canadian citizenship card, immigration papers, etc.). IF YOU WERE BORN IN Attached
CANADA AND LIVED THERE CONTINUOUSLY UNTIL YOUR DEPARTURE, THIS
PROOF IS NOT REQUIRED.
- proof of the dates of your entry into and your departure from Canada
(passports, visas, ship or airline tickets, etc.) Attached

B. BENEFITS BASED ON CONTRIBUTIONS PAID TO THE CANADA PENSION PLAN

SINCE JANUARY 1966:
Retirement Pension

Complete: Sections 1, 2, 4 and 7 Verified by:

Submit: Indicate: Year Month Day
- a birth certificate - date of birth
Survivor's Pension Surviving Child's Benefit Death Benefit
Complete: Sections 1, 2, 5, 6 (if necessary) and 7
Submit*: Indicate:
Year Month Day
- a death certificate - date of death

- a birth certificate for the - date of birth of Year Month Day

deceased contributor the deceased
contributor

- a birth certificate for the survivor - date of birth of Year Month Day
and each dependent child the survivor

- date of Year Month Day

- a marriage certificate marriage
* If applying for a Death Benefit only, submit the contributor's death and birth
certificates only.
If you wish to apply for a Canada Pension Plan Disability Benefit, please complete form CDN-USA 1 (DI)
which is available on this website and from your nearest social security office.

SC ISP-5054-USA (2024-01-01) E 1/6

 Canadian Social Insurance Number PROTECTED B (when completed)

SECTION 2 - GENERAL INFORMATION ABOUT THE CONTRIBUTOR OR APPLICANT FOR AN OLD AGE
SECURITY PENSION (To be completed by all applicants)

3. Optional: Mr. Mrs. Miss Ms.

4. Given Name and Initial Family Name Family Name at Birth

5. Address (No. and Street, Apt. No.) City, Town or Village 6. Mailing Address:
same as question 5 or

Province or Territory Country Postal Code

7. Place of Birth 8. Name on Canadian Social Insurance Card

same as question 4 or

9. Indicate periods of residence and/or periods of employment in a country other than Canada and the United States.
Residence Employment Has a benefit
Name of Social Security been
Country Number in that From To From To requested?
Country
Year Month Year Month Year Month Year Month Yes No

10. Since January 1, 1966, have you or your spouse or Contributor Spouse or Common-law partner
common-law partner been eligible for Canadian Family
Allowances or the Child Tax Benefit for a child born after Yes No Yes No
December 31, 1958?
11A Marital Status
Single Married Separated Divorced Common-Law Surviving spouse or
common-law partner
11B Spouse's or Common-law partner's Full Name 11C Spouse's or Common-law Year Month Day
partner's Date of Birth

SECTION 3 - TO BE COMPLETED WHEN APPLYING FOR AN OLD AGE SECURITY PENSION

(Otherwise, proceed to SECTION 4)

12. If born outside Canada, give Year Month Day Place of Entry
date and place of entry into
Canada.
13. Indicate the legal status of your residence in Canada at the time of your departure from Canada.

Canadian Citizen Temporary Resident Permit Holder

(formerly known as Minister's Permit)
Permanent resident(formerly known Other (please specify)
as Landed Immigrant)

SC ISP-5054-USA (2024-01-01) E 2/6

 Canadian Social Insurance Number PROTECTED B (when completed)

14. List the places where you have lived from birth to the present. Do not include changes within the same city, town
or village.(If more space is needed, provide the information on a separate sheet of paper.)
From To
City, Town
Province or State Country
Year Month Year Month or Village

15. Give name, address and telephone number of two persons, not related to you by blood or marriage, with whom we
can confirm the facts of your residence in Canada.
Telephone Number
Address (including area, city or regional code)

16. Are you considered a resident If no, is your net world income Yes No
of Canada for tax purposes? Yes No for the year 2023 less than
$86,912 in Canadian dollars? (See the guide for more information)

SECTION 4 - TO BE COMPLETED WHEN APPLYING FOR A CANADA PENSION PLAN RETIREMENT PENSION
(Otherwise, proceed to SECTION 5)
17. When do you want your pension to start?
IMPORTANT: Please read the information sheet before completing this section.

As soon as I qualify
or
Select one only At the age of 65 (your pension will start the month after your 65th birthday)
or
As of (indicate date)
Year Month

SECTION 5 - TO BE COMPLETED WHEN APPLYING FOR A SURVIVOR'S PENSION OR A DEATH BENEFIT

(Otherwise, proceed to SECTION 6)

A. GENERAL INFORMATION ABOUT THE APPLICANT

18A. Optional: Mr. Mrs. Miss Ms.

18B. Given Name and Initial Family Name Family Name at Birth

19. Address (No. and Street, Apt. No.) City, Town or Village 20. Mailing Address:
same as question 19 or

Province or Territory Country Postal Code

21. Applicant's relationship to the deceased contributor

SC ISP-5054-USA (2024-01-01) E 3/6

 PROTECTED B (when completed)

Canadian Social Insurance Number

A. GENERAL INFORMATION ABOUT THE APPLICANT (CONTINUED)

22. Is there an executor, administrator or legal representative of the estate of the deceased contributor?

Yes If "Yes", indicate whether Same as in questions 18 and 19 or

No As shown below

Given Name Family Name

Address (No. and Street, Apt. No.) City, Town or Village

Province or Territory Country Postal Code

B. INFORMATION ABOUT THE SURVIVOR

23. Social Insurance Number in Canada 24A.
Optional: Mr. Mrs. Miss Ms.

24B. Given Name Family Name Family Name at Birth

Same as in question 18 or Same as in question 18 or Same as in question 18 or

25. At the time of the contributor's death, were you residing 26. At the time of the contributor's death, were you
with him or her? married to him or her?
Yes No Yes No

SECTION 6 - TO BE COMPLETED WHEN APPLYING FOR A SURVIVING CHILD'S BENEFIT

(Otherwise, proceed to SECTION 7) Questions 28 and 29 to be completed only when the applicant
is not the person named in question 18.
27. For use by the Social Security
Date of Birth
Full Name of Child Institution of the United States
only
Year Month Day
Verified by:

28A. Optional: Mr. Mrs. Miss Ms.

28B. Given Name Family Name

29. Address (No. and Street, Apt. No.) City, Town or Village

Province or Territory Country Postal Code

SC ISP-5054-USA (2024-01-01) E 4/6

 Canadian Social Insurance Number PROTECTED B (when completed)

SECTION 7 - TO BE SIGNED BY THE APPLICANT AND, IF APPLICANT SIGNS WITH MARK, BY A WITNESS.
NOTE: If you are applying on behalf of the applicant, indicate on a separate sheet of paper your
full name and address, and the reason you are making this application.
30. Declaration and signature

I declare that, to the best of my knowledge, the information given in this application is true and complete. I
authorize the social security institution of the country which is a Party to this Agreement to furnish to Service
Canada all the information and evidence in its possession which relate or could relate to this application for
benefits.
The information you provide is collected under the authority of the Old Age Security Act (OAS Act) and the
Canada Pension Plan legislation to determine your eligibility for benefits. The Social Insurance Number (SIN) is
collected under the authority of section 52 of the Canada Pension Plan Regulations, section 15 of the OAS
Regulations and in accordance with Treasury Board Secretariat Directive on the SIN as an authorized user of
the SIN. The SIN will be used to ensure an individual's exact identification so that contributory earnings can be
correctly posted allowing for benefits and entitlements to be accurately calculated. The SIN will also be used
for income verification purposes with the Canada Revenue Agency to deliver better service to you, and
minimize government duplication.
Submitting this application is voluntary. However, if you refuse to provide your personal information, the
Department of Employment and Social Development Canada (ESDC) will be unable to process your
application.

The information you provide may be used and/or disclosed for policy analysis, research, and/or evaluation
purposes. In order to conduct these activities, various sources of information under the custody and control of
ESDC may be linked. However, these additional uses and/or disclosures of your personal information will
never result in an administrative decision being made about you (such as a decision on your entitlement to a
benefit).
The information you provide may be shared within ESDC, with any federal institution, provincial authority or
public body created under provincial law with which the Minister of ESDC may have entered into an
agreement, and/or with nongovernmental third parties for the purpose of administering the Canada Pension
Plan, the OAS Act, other acts of Parliament and federal or provincial law as well as for policy analysis,
research and/or evaluation purposes. The information may be shared with the government of other countries in
accordance with agreements for the reciprocal administration or operation of that law, of the OAS Act and of
the Canada Pension Plan.
Your personal information is administered in accordance with the OAS Act, the Canada Pension Plan and the
Privacy Act. You have the right of access to, and to the protection of, your personal information. It will be kept
in Personal Information Bank ESDC PPU 146 (CPP) and Personal Information Bank ESDC PPU 116 (OAS).
Instructions for obtaining this information are outlined in the government publication entitled Info Source, which
is available at the following Web site address: www.infosource.gc.ca. Info Source may also be accessed
online at any Service Canada Centre.
NOTE: If you make a false or misleading statement, you may be subject to an administrative monetary penalty
and interest, if any, under the Canada Pension Plan or the Old Age Security Act, or may be charged with an
offence. Any benefits you received or obtained to which there was no entitlement would have to be repaid.

Signature of
Applicant

Date
Year Month Day Telephone Number
(including area, city or regional code)

NOTE: Signature by mark is acceptable if witnessed by any responsible person who must complete the
declaration on the following page.

SC ISP-5054-USA (2024-01-01) E 5/6

 Canadian Social Insurance Number PROTECTED B (when completed)

31. Declaration of witness

I read the contents of this application to the applicant who appeared to fully understand and who made his
or her mark in my presence.

Signature of Witness Name of Witness (Please print)

Address of Witness

TO BE COMPLETED BY THE LIAISON AGENCY IN CANADA

Eligibility Date - OAS Eligibility Date - CPP Date of receipt Age Residence Status
Year Month Day Year Month Day Year Month Day A B T X Y Z O

Payment Date - OAS Payment Date - CPP Elective Date Residence Residence
(Transitional Rules)
Year Month Day Year Month Day Year Month Day
3 (1) (b) 3 (1) (c) 3 (1.1)

Aggregate I certify that the applicant is eligible to receive the benefit(s) indicated as of the date(s) shown
and that the benefit(s) is (are) payable under the provisions of the Old Age Security Act
or the Canada Pension Plan.

Certified by: Date

Rounded Down

Verified by: Date

Service Canada delivers Employment and Social Development Canada

programs and services for the Government of Canada

Disponible en français

SC ISP-5054-USA (2024-01-01) E 6/6