Secure Certificate of Indian Status (SCIS) Guarantor Declaration

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Protected B (When Completed)

General Information

A guarantor is a person other than yourself who confirms your identity and performs the required tasks free of charge.

Your guarantor:

  • must be 18 years of age or older;
  • must have known you personally for at least two (2) years. To know an applicant personally means that the guarantor is able to confirm aspects of your personal attributes such as name, approximate age, place of birth, physical description and some personal history such as place of residence;
  • must be accessible for Aboriginal Affairs and Northern Development Canada (AANDC) to contact; and
  • must be residing in Canada or the United States.

Your guarantor must be someone from the following list:

  • Indian Registrar or an Indian Registry Administrator;
  • Commissioner for Oaths;
  • Elected Chief or Councillor of the band to which the applicant belongs;
  • Dentist, medical doctor, optometrist, pharmacist or chiropractor;
  • Judge, magistrate or police officer (First Nations, municipal, provincial, territorial or RCMP);
  • Lawyer;
  • Mayor;
  • Minister of a religion authorized under a provincial, territorial law to perform marriages;
  • Notary public;
  • Postmaster/Postmistress;
  • Principal of a primary or secondary school;
  • Professional accountant;
  • Professional engineer;
  • Senior administrator or teacher in a community college or university;
  • Registered social worker;
  • Veterinarian;

Family members as guarantors:

A family member may act as guarantor if he/she is 18 years of age or older, residing in Canada or the United States, is available to be contacted by AANDC for verification, and meets the guarantor criteria.

Please note that a parent or legal guardian applying for a SCIS for the child or dependent adult cannot also act as a guarantor for the child or dependent adult.

When a guarantor is being used for mail-in applications (in-Canada only) your guarantor must:

  • Complete and sign the Guarantor Declaration (83-111E);
  • Write “This is a true likeness of (the name of applicant/child/dependent adult)” on the back of one (1) of the two up-to-date passport style photographs. The guarantor must also sign and date the back of the photograph; and
  • Sign and date a photocopy of the front and back of the documents that support the applicant’s identity.

When a guarantor is being used in lieu of ID (in-Canada only) your guarantor must:

  • Complete and sign the Guarantor Declaration (83-111E); and
  • Write “This is a true likeness of (the name of applicant/child/dependent adult)” on the back of one (1) of the two up-to-date passport style photographs. The guarantor must also sign and date the back of the photograph.

If you do not have access to an eligible guarantor who has known you for at least two (2) years, you must complete a Statutory Declaration in Lieu of Guarantor (83-112E) and provide two (2) references who are not relatives. This form must be completed before a Commissioner for Oaths, Notary Public or Lawyer.

 

Privacy Act Statement

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. 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 .

NOTICE TO ALL APPLICANTS AND GUARANTORS

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 statements 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.


Applicant Information

 

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

1. Applicant’s Family Name (Last Name)


2. Applicant’s Given Name(s)



Child’s/Dependent Adult’s Family Name (Last Name) (to be completed only if Guarantor Declaration is in support of a Child/Dependent Adult Application (83-108E/83-131E)



Child’s/Dependent Adult’s Given Name (to be completed only if Guarantor Declaration is in support of a Child/Dependent Adult Application (83-108E/83-131E)




3. Indian Registration No. 
(For Adult application, include applicant's Registration No.,
for child’s or dependent adult’s applications, include
Child’s/Dependent Adult’s Registration No.)

 
4. I certify that I am the named individual above (and, as necessary, the parent or legal guardian of the child or dependent adult named above).
Signature of Applicant


X


Date (YYYYMMDD)






Guarantor Information and Declaration

1. Guarantor’s Family Name
(Last Name)


2. Guarantor’s Given Name(s)



3. Address of Permanent Residence

Number/Street/Apartment
/P.O.Box


City/Town




Province/Territory
/State



Postal/ZIP Code




4. Guarantor’s Occupation(See list under General Information)


5. Name of Firm/Organization



6. Telephone No. (Daytime)

(      )
7. I have known the applicant for
_____________ years (minimum of 2 years)


I solemnly declare that I am at least 18 years of age and confirm that I have known the applicant identified above personally for at least two (2) years. I declare that any false or misleading statements on this Guarantor Declaration or relating to any document in support of this application, including concealment of any material fact, may lead to refusal or revocation of an SCIS and be grounds for criminal prosecution.

Signature of Guarantor

X
Date (YYYYMMDD)




INTER 83-111E 2012-10-01 7530-20-005-9354