Registration and Secure Certificate of Indian Status (in-Canada SCIS) Statutory Declaration in Lieu of Guarantor

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Privacy Act Statement

The personal information provided in this document is collected under the authority of the Indian Act to determine the applicant's entitlement to inclusion in the Indian Register and, if applicable, in a Band List maintained by the Department of Indian Affairs and Northern Development (DIAND), and to obtain an in-Canada format of a Secure Certificate of Indian Status (in-Canada SCIS). The applicant has the right to the protection of and access to his or her personal information under the Privacy Act. The personal information will be retained indefinitely by DIAND . Details of the collection, use, disclosure and retention of personal information are described in the Personal Information Bank INA PPU 110.

Notice to all applicants

The in-Canada SCIS remains at all times the property of the Government of Canada and must be used only by the person in whose name it is issued. Any false or misleading statements on this form or relating to any document in support of this application, including concealment of any material fact, selling the in-Canada SCIS or permitting any other individual or agency to use the in-Canada SCIS may lead to criminal prosecution and is cause for revocation of the in-Canada SCIS and refusal of any future SCIS issuance.


This form must be completed and signed before a Commissioner for Oaths, Notary Public or Lawyer.

A. Applicant Information

Note: For purposes of this statutory declaration, the applicant is the adult applying for registration or the parent/legal guardian applying on behalf of a child (15 years of age or younger) or dependent adult.

Addresses (List your addresses in the last FIVE (5) years, beginning with the most current)

Number/Street/Apartment/P.O.Box City/Town Prov./Terr./State From To

In the last FIVE (5) years,

my employers were


I was attending education institutions as follows:

Business/School Address Telephone
Nature of Employment/
From To

B. References

I have personally sought the agreement and consent of the TWO (2) following persons, who are not my relatives and have known me for at least TWO (2) years, to be contacted to confirm my identity:

One reference must sign one of the photos on the reverse side with the statement "This image is a true likeness of (the name of applicant)". BOTH references are required to sign and date a copy of the front and back of the identity documents.

C. Applicant Declaration

For mail-in application only: I have presented to the references named above for signature copies (both sides) of my identity documents which bear my photograph and signature and a passport type photograph.


Declaration: I solemnly declare that I am unable to obtain an eligible guarantor as defined in the Guarantor Declaration (83-120E) and to my knowledge, the statements made in this declaration are true and the photos enclosed are a true likeness of me or the child/dependent adult on whose behalf I am applying.

Signature of Applicant:

D. Official Information and Declaration

Declaration made before me on:

Signature of Official (Affix stamp):

INTER 83-119E 2011-01-31

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