Appendix 4 - Affidavit (Exemption for Non-Canadian Courtesy Credit)

Sample form only: do not complete

This form is for reference purposes only. It is not to be completed in this format.

To complete this and submit it to the CRTC, download the form.

Canadian Program Certification

I, ___________________________________, of the City of _____________________________, in the Province/State of ____________________________, HEREBY MAKE OATH AND SAY:

  1. THAT as a representative of __________________________________(“Company”) whose registered office is situated in the City of ______________________________________,  and which:

    1. arranged or has been engaged by ________________________________________________ to arrange (financing) and/or (distribution), and/or

    2. provided or will provide services to the production

      under the direct supervision and control of _________________________________, the Canadian producer(s), (the “Producer”), for the production entitled ___________________________________________________ (the “Production”),

  2. THAT I was/will be present on the set during shooting as an observer for _________ days which represents no more than 25 per cent of principal photography.

  3. THAT the Producer has agreed to use its best endeavour to have accorded to me a(n)_________________________________ (eg. executive producer, etc.) courtesy credit.

  4. THAT I have been given to understand by the Producer that the Canadian Radio-television and Telecommunications Commission (CRTC) requires a duly notarized affidavit from me outlining my duties on the said Production before an application for Canadian program certification can be considered.

  5. THAT accordingly, neither I nor the Company, will exercise any administrative or creative function before, during or after the Production or issue any instruction to any writer, actor, director or crew member, except under the specific direction or with the approval of the Producer.

  6. THAT I have not nor will not assume any responsibility for the expenditure of any production money, or order any goods or services of any kind, in connection with the Production.

  7. THAT I have not nor will not negotiate with anyone or represent the Producer or the Production, in any way at all, except to arrange the foreign distribution or financing, or to provide services to the Production, under the strict supervision and control of the Producer.

    SWORN before me at the City of ___________________________, in the, Province/State of ___________________________, this ______ day of __________________, 20____.



    Notary Public or Commissioner of Oaths (Affix seal)

CRTC - Appendix 4 (2017-01-25) - Canadian Program Certification - Affidavit 

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