IN-CANADA Secure Certificate of Indian Status (SCIS) Adult Application for Applicants sixteen (16) Years of Age or Older

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PROTECTED B (When Completed)

Privacy Act 

Personal information provided in this document is collected by Aboriginal Affairs and Northern Development Canada (AANDC) under the authority of the Indian Act. Individuals have the right to the protection of and access to their personal information under the Privacy Act. The information provided is voluntary. Failure to provide sufficient information may render the application invalid or may result in processing delays. Information provided is subject to routine verifications, including verifications against the Indian Register. AANDC may, for the purpose of receiving applications, collect personal information from Indian Registry Administrators. Furthermore, personal information will be disclosed to a third party for the purpose of printing the SCIS. In the performance of these duties, personal information will be processed and used in accordance with the provisions of the Privacy Act. Further details on the collection, use and disclosure of personal information are described under the Personal Information Bank INA PPU 110 .


Helpful Tips for Completing Your SCIS Application

  • Complete all sections and sign the application. Failure to complete all the sections of this form and submit all necessary documentation will result in your application being refused and returned to you.
  • Personal information (Section A)
    If the name written in Section A differs from that on your birth certificate or identification documents, the following original documents may be required: adoption order, legal name change, marriage certificate or other court document.

    If this name differs from that in the Indian Register, a change to your information in the Indian Registry System must be processed by an Indian Registry Administrator or at an AANDC Regional Office prior to applying for the SCIS.
  • Proof of Birth (Section B)
    Your original birth certificate must be submitted. Please note: If you were born in the province of Québec, only birth certificates issued on or after January 1, 1994, by the Directeur de l’état civil will be accepted. If you were born in the province of Manitoba, Manitoba Division/District Registrar birth certificates are not accepted. If you are over the age of 65, a baptismal certificate issued by a church is acceptable.
  • Previous Secure Certificate of Indian Status (SCIS) (Section C – replacement or renewal applications only)
    If you have been previously issued a SCIS, it must be presented, regardless of its validity. If your SCIS has been lost, stolen, damaged, or destroyed, a Statutory Declaration (83-113E), completed and signed in the presence of a Commissioner for Oaths, Notary Public or Lawyer must also be submitted.
  • Documents to Support Your Identity (Section D)
    Provide one (1) SCIS, Canadian or United States Passport, Enhanced Driver’s Licence/Identity Card, NEXUS or FAST card or two (2) valid federal, provincial, territorial or state government issued identity documents. Identity documents presented must include a combination of your name, photograph and signature. If you are unable to provide these documents, one valid identity document is sufficient when accompanied by a Guarantor Declaration (83-111E). Your guarantor must sign and date the back of one (1) of the two up-to-date passport style photographs. Further information regarding these requirements can be found on the Guarantor Declaration (83-111E).
  • Activation Code (Section F)
    Select a four digit numeric activation code. You will be required to write your activation code twice. IMPORTANT: Please be sure to tear off your portion of the activation code. Upon receipt of your SCIS, you will be required to activate your SCIS via telephone using your selected activation code.
  •  Photographs
    Two (2) unaltered, identical, commercial grade, passport style photographs are required to be submitted with your application. See the Photographs section for SCIS photo specifications.
  • Mail-in applications
    If you are applying for a SCIS by mail, a Guarantor Declaration (83-111E) must be completed. Your guarantor must also sign the back of one (1) passport style photograph and a photocopy (both sides) of each document to support your identity. Your original birth certificate and any name-linking documents must be included. Original documents will be returned to you by mail after they have been processed. Applications are to be mailed to:
    SCIS national Processing Unit, 10 Wellington Street, Gatineau, QC K1A 0H4.

Further information regarding the Secure Certificate of Indian Status is available by telephoning toll-free 1-800-567-9604, e-mailing InfoPubs@aandc-aadnc.gc.ca or viewing the AANDC website.


Photographs

Important: Two (2) unaltered, identical, commercial grade, passport style photographs are required to be submitted with your application.

Size and paper

  • The length of the face on the photographs from chin to crown (natural top) of head must be between 31 mm (1 1/4 in.) and 36 mm (1 7/16 in.).
  • Photographs must measure 50 mm x 70 mm in size (2 inches wide x 2 3/4 inches long).
  • Photographs must be a close-up of the head and shoulders so that the face covers approximately 25% of the photograph.
  • Photographs must be printed on plain, high quality photographic paper. Heavyweight paper is not acceptable.
  • Colour or black and white photographs are acceptable.

Image information

  • The photographs provided will be printed on the SCIS.
  • Photographs must be taken against a plain white or light-coloured background so that the applicant’s features are clearly distinguishable against the background.
  • Shadows are unacceptable. Lighting must be uniform to avoid shadows across the face or shoulders, around the ears or in the background.
  • There must be no reflection or glare on the face or glasses.
  • The applicant must show a neutral facial expression (no smiling, mouth closed).
  • Eyes must be open and clearly visible. Glasses, including tinted prescription glasses, are acceptable as long as the eyes are clearly visible and there is no glare in the glasses.
  • Sunglasses are unacceptable.
  • Photographs must show a full head without any head covering, unless worn for religious or medical reasons. However, both edges of the face must be clearly visible.
  • Photographs must show a full front view of the applicant’s face and top of the applicant’s shoulders must be squared to the camera (the image of the applicant’s face and shoulders must be centred in the photograph).
  • Photographs must be clear, sharp and in focus.
  • Photographs must be original and not taken from an existing photograph.
  • Photographs must have been taken within the last 12 months.

Photographer

  • The name of the photographer or studio, the address and the date the photograph was taken (not the date the photograph was printed) must be provided directly on the back of one photograph.
  • Ensure your guarantor signs the back of one (1) photo, if you are submitting your application by mail.
  •  

Please Note U.S. passport specifications are not the same and do not meet SCIS photo specifications.

Notice To All Applicants

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

Reason for application:

(Please check one)

  _  Initial SCIS
  _  Replacement SCIS
  _  Renewal SCIS


A Personal Information

(Complete in block letters using black or dark blue ink)

1. Family Name (Last name)


2. Given Name(s)


3. Alias


4. Family Name (Last Name) at Birth (If different from above, name-linking documents must be provided)


5. Date of Birth (YYYYMMDD)


6. Sex

  _ M   _ F
7. Indian Registration No.

 
8. Band Name


9. Mailing Address (Address where the SCIS will be sent) Number/Street/Apartment/P.O.Box


City/Town




Province/Territory/State




Postal/ZIP Code




10. Telephone No. (Daytime)

(      )

11. Telephone No. (Evening)

(      )
12. Specimen Signature: The signature below will appear on the SCIS that will be issued to you. Sign your name inside the box below without the signature touching the border. You may sign with an "X", in syllabics or another language, as long as this is your usual legal signature.



 

 

 

 

 

Signature of Applicant

B Proof of Birth

Please check one

  _  Original birth certificate issued by a Vital Statistics Agency in a Canadian Province or Territory

 or

  _  Original birth certificate issued by a U.S. State/County/City/Township

 or

  _  Original birth certificate issued by a non-U.S. or non-Canadian jurisdiction

 or

  _  Original baptismal certificate issued by a church, if applicant is 65 years of age or older

C Secure Certificate of Indian Status (SCIS)

(Required for replacement and renewal applications only) (Complete if you have previously been issued a SCIS regardless of its validity)

1. Serial No.


2. Renewal Date (YYYYMMDD)


NOTE: If your SCIS regardless of its validity is lost, stolen, damaged or destroyed, a SCIS Statutory Declaration Concerning a Lost, Stolen, Damaged or Destroyed SCIS (83-113E) must also be completed.


D Documents to Support Identity

(One ID is required if it is a SCIS, a valid Canadian or U.S. Passport, Enhanced Driver’s Licence/Identity Card, NEXUS or FAST Card)

1. Document Type


Document No.




Expiry Date
(YYYYMMDD)



Name of Bearer as it appears on document



2. Document Type


Document No.




Expiry Date
(YYYYMMDD)



Name of Bearer as it appears on document




E Declaration

REMINDER: Complete all sections and sign the application. Failure to complete all the sections of this form and submit all necessary documentation will result in your application being refused and returned to you.

I solemnly declare that the photos enclosed are a true likeness of me. I solemnly declare that any documents provided to support the application are unaltered and that all of the statements made in this application are true. I solemnly declare that I have read and understood the Privacy Act Statement and the Notice to All Applicants.

Signature of Applicant

X
Date (YYYYMMDD)



F Activation Code

Please select a four (4) digit numeric activation code and record the same code in both of the sections provided (below).

Note: This is the code that you will use to activate your SCIS upon receipt.



 





83-130E 2012-10-01 7540-20-006-5044


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SCIS Activation Code (Tear-Off Along the Dotted Line)

Instructions on how to activate your SCIS using this four (4) digit activation code will accompany your SCIS.

Tear this section and keep it safe.
 SCIS Activation Code :