IMM 5409 how to fill with different countries

[Anford]

OK this is so confusing but let's do it

I'm filling the form of "Statutory Declaration of Common-Law Union (IMM 5409)" and the thing is, that I'm from Czech Republic (Country 1), my girlfriend from Belgium (Country 2) and we are signing this document in Germany (Country 3). Of course, we are signing it for Canada (Country 4)

How do we fill the application's countries? I'm asking only about first 8 fields.

Thank you!

 

[canadianwoman]

Are you currently living together in Germany? If yes, then fill out the country and province or state or territory and the city with 'Germany' and the state and city you are living in.

If you are no longer living together, put the place where you were living together for the one year you need to be common-law.