This is what I used:
AFFIDAVIT OF SEPARATION:
I, ______________________________, date of birth _______________ (mm/dd/yyyy) and holder of Passport no. _____________ issued by (country) _________________________ hereby certify that I am separated and estranged from my spouse (name of spouse)_______________________ date of birth _______________ (mm/dd/yyyy) and holder of Passport no. _____________ issued by (country) _________________________ since _______________ (mm/dd/yyyy). I further certify that I do not intend to reconcile with my spouse.
I intend to take following legal action with regard to my marital status:
_________________________________________________________________________
I, __________________________________, further certify that my spouse (name of spouse)_______________________ does not wish to undergo medical examination and police clearance process for the purposes of immigrating to Canada. I understand that such a refusal will render my spouse ineligible to be sponsored for immigrating to Canada at any time in the future if reconciliation were to occur prior to any legal changes to my marital status cited above.
Under penalties of perjury, I certify the above representations to be true as of the date shown below.
__________________________________________ ______________________
Your name (Signature) Date
__________________________________________ ______________________
Signature Notary Public / Commissioner of Oaths Date
