Transfer of Land in an Indian Reserve

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(under the Indian Act)

PROTECTED B (When Completed)

Privacy Act Statement

The information you provide in this document is collected under the authority of Section 24 of the Indian Act for the purpose of determining that the transferor of the property and the individual receiving the property are registered members, either holding lawful possession and eligible to lawful possession on the said reserve. Information on individuals is used by Aboriginal Affairs and Northern Development Canada employees who need to know the information in order to respond to your request and/or the program requirements. The personal information will be kept for a period of 30 years and then transferred Library and Archives Canada. Individuals have the right to the protection of and access to their personal information under the Privacy Act . The information collected is described under the Personal Information Bank AANDC PPU 090 .

I/We _____________________________________________________________________

of Band No.(s) ___________________________________________________________

member(s) of the ___________________________________________________ Indian Band registered in lawful possession of all and singular that certain parcel of land being: (Describe only land being transferred)

____________________________________________ Indian Reserve No. ______________

in the Province of ___________________________________________________________

DO HEREBY in consideration of the sum of _________________________________Dollars,

paid to me/us by _______________________________________ the receipt of which sum

is hereby acknowledged transfer to the said ____________________________________

No. ___________________ Band ______________________________________________

All my/our estate and interest in the said parcel(s) of land granted to me pursuant to the provision of the Indian Act.

*(If joint tenancy and not tenancy in common specify. Not applicable in Province of Quebec.)

In witness whereof I/We, have hereunto subscribed my/our name(s)

this ___________________
of ___________________,

Signed in the presence of



  1. Where the Transferor signs by "mark", TWO witnesses are required, neither of who may sign by "mark".
  2. Affidavit of Execution to be completed on the following page by the witness. Where more than one witness, additional Affidavits of Execution are required.
  3. Where only one witness to both signature insert "as to both signatures".


)   I, ____________________________
)   of the City of __________________

)   in the Province/
)   Territory of __________________
)   make oath and say:
)  __________________________
)  __________________________


  1. That I was personally present and did see the within instrument duly executed by:_________________________________________________
    (Where execution by mark insert applicable clause)
  2. That I know the said party(ies) and that the said party(ies) in my belief is/are the full age of_______________ years.
  3. That I am the subscribing witness to the said instrument



at ____________________________________,

in the Province/Territory of _______________,

This________ of ______________, _________.
        (Day)           (Month)           (Year)

A Notary Public/Commissioner for Oaths in and for the

Province/Territory: ________________________

My commission expires: ____________________


Where the transfer is signed by mark the following should be added to the attestation clause to be signed by the witness:

"The said transfer having been first truly and audibly read over to him/her, when he/she appeared to understand it, and made his/her mark hereto in our presence as a foresaid."

INTER 83-017E (2013-01-23) (A)