Fillable APPLICATION FOR REGISTRATION ON THE INDIAN REGISTER AND FOR THE SECURE CERTIFICATE OF INDIAN STATUS (Natural Resources Canada)

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APPLICATION FOR REGISTRATION ON THE INDIAN REGISTER AND FOR THE SECURE CERTIFICATE OF INDIAN STATUS (Natural Resources Canada)

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PROTECTED B (When Completed)
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INTER 81-010E 2009-10-19
INTER 83-168E 2018-09-12 (A)
APPLICATION FOR REGISTRATION ON THE INDIAN REGISTER AND
FOR THE SECURE CERTIFICATE OF INDIAN STATUS (SCIS)
(FOR ADULTS 16 YEARS OF AGE OR OLDER)
GENERAL INFORMATION
► Please review the instructions (83-168E-I) to complete the application.
► To complete the application, you may need to include a Guarantor Declaration (form 83-169E) or a Statutory Declaration in Lieu of
Guarantor (form 83-170E). A Declaration is required if the application is sent by mail.
► To obtain forms or the instructions, visit canada.ca/indian-status, or call 1-800-567-9604.
► Original documents included with the application will be returned to you.
► If you need to include a Guarantor Declaration form with the application, you must submit the form with the signature of the
guarantor. A guarantor is a person who can confirm your identity.
HOW TO SUBMIT YOUR APPLICATION
IN PERSON:
• At the regional office nearest you. As an appointment may be required, it is recommended that you call ahead of time.
• For the list of regional offices, visit canada.ca/indian-status, or call 1-800-567-9604.
BY MAIL:
• If you send the application by mail, you must include a Guarantor Declaration form with the signature of the guarantor.
• The guarantor must sign and date the photocopies of the front and back of your supporting identity documents.
Note: You must still include your original proof of birth document.
• If you are applying for registration AND for the Secure Certificate of Indian Status, the guarantor must also sign and date the back of
one (1) of your photos and write the statement “this is a true likeness of (your name)”.
Send the application to:
National Registration Processing Unit
10 Wellington Street
Gatineau, Quebec K1A 0H4
For applications made under Bill S-3: An Act to amend the Indian Act in response to the Superior Court of Quebec decision in
Descheneaux c. Canada (Procureur général), or under Bill C-3: Gender Equity in Indian Registration Act, send to:
Application Processing Unit
Box 6700
Winnipeg, Manitoba R3C 5R5
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CHECKLIST
Application Form
Section 7 of the application must be signed and dated.
Birth Document
Include an original birth certificate listing the names of your parents. A photocopy is not acceptable.
Note: If you were adopted, you must provide an original birth certificate listing the names of the your adoptive parent(s).
Supporting Identity Documents
Supporting identity documents must contain the following four (4) elements: full name, date of birth, photo and signature.
► Include with the application:
One (1) identity document that contains all the elements listed above, OR
More than one identity document that, combined together, contain all the elements listed above, OR
One (1) identity document that contains some but not all the elements listed above and a Guarantor Declaration form.
► You may include:
Original identity documents (recommended if submitting the application in person), OR
Photocopies of the supporting identity documents and a Guarantor Declaration form. The guarantor must sign and date the
photocopies of the front and back of the identity documents (recommended if sending the application by mail).
Name-Linking Document(s)
If you are applying under a name that is different than the name on your birth certificate, you must provide a name-linking document, such
as a marriage certificate and a legal name change certificate.
► If applicable, include with the application:
An original name-linking document, OR
A photocopy of the name-linking document and a photocopy of a government-issued identity document that has your name as it
appears on the application form (for example, a driver's licence).
Photos
Include two (2) unaltered, identical, Canadian passport-style photos. The name and address of the studio or person who took the
photo, and the date the photo was taken must be indicated on the back of one (1) photo. Photos are required only if a Secure
Certificate of Indian Status is requested.
Adoption
► If you were adopted as a child, include with the application
:
A photocopy of the adoption order or photocopy of the letter from the Social Services authorities confirming the details of the
adoption: names of the adoptive parent(s), full name of adoptee as it appears on the adoption order, and date and place of
adoption.
A signed and dated consent form giving the Indian Registrar permission to contact the Social Services authorities for information on
your birth ancestry. To obtain the consent form, call 1-800-567-9604.
A photocopy of your pre-adoption birth certificate (optional, if available).
Mail-In Application
If submitting the application by mail, include a Guarantor Declaration form (see instructions on previous page).
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APPLICATION FOR REGISTRATION ON THE INDIAN REGISTER AND
FOR THE SECURE CERTIFICATE OF INDIAN STATUS (SCIS)
(FOR ADULTS 16 YEARS OF AGE OR OLDER)
Privacy Act Statement
This statement outlines the purposes for the collection and use of personal information. Only information needed to respond to program requirements will
be requested. Collection, use, and disclosure of personal information are in accordance with the Privacy Act. In some cases, information may be disclosed
without your consent pursuant to subsection 8(2) of the Privacy Act. The authority to collect and use personal information for the Indian Registration and
the Secure Certificate of Indian Status programs is derived from the Indian Act. We use the personal information we collect to determine entitlement to
registration in the Indian Register and membership in a First Nation for which the Band List is maintained by the Department, to issue a Secure Certificate
of Indian Status to registered persons, and for the provision of benefits and services conferred exclusively to those who are registered. We may share the
personal information you provide as outlined under Personal Information Bank AANDC PPU110 (Info Source http://www.aadnc-aandc.gc.ca/
eng/1100100011039/1100100011040). The information collected is retained by the Department for 30 years after the last administrative action and then
transferred to Library and Archives Canada (or as described in the Personal Information Bank). As stated in the Privacy Act, you have the right to access
the personal information you give us and request changes to incorrect information. If you have questions or wish to notify us of incorrect information, you
may call us at 1-800-567-9604. For more information on privacy issues and the Privacy Act in general, you can consult the Privacy Commissioner at
1-800-282-1376.
NOTICE TO APPLICANTS
If you identify with an Indigenous group that is not recognized under the Indian Act (non-status), you may wish to consult with that group before
proceeding with an application for registration for yourself, a minor child or dependent adult. Registration under the Indian Act in Canada may
affect your entitlement to join or be recognized by some non-status groups and your entitlement to the programs and services they may offer. The
Indian Registrar does not have the power to remove a name from the Indian Register if the individual has been correctly registered, even when
the individual wishes to deregister.
The Secure Certificate of Indian Status (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 statement with respect to this application and any supporting document, including the
concealment of any material fact, selling or permitting the use of your SCIS by any other individual or agency may lead to criminal prosecution,
and is cause for revocation of your SCIS and refusal to issue a SCIS in the future. Any false or misleading statement, including the concealment
of any material fact, may lead to a review of your entitlement to registration and revocation of your registered Indian status.
► Complete this form online, or write in block letters using black or dark blue ink.
SECTION 1: Personal Information
Family Name Given Name(s)
Family Name at Birth (if different from above) Alias / Cultural Name (if applicable)
Sex (as per Birth Certificate)
Male Female
Date of Birth (YYYYMMDD)
Permanent Address Address is on Reserve
Number, Street, Apartment, P.O. Box
City/Town Province/Territory (Canada)
State (USA)
Postal/ZIP Code
Telephone Number (Daytime) Telephone Number (Other) Email Address
Mailing Address (if different from above)
Number, Street, Apartment, P.O. Box
City/Town Province/Territory (Canada)
State (USA)
Postal/ZIP Code
SECTION 2: First Nation/Band Choice
(If your parents are affiliated with different First Nations/Bands, indicate your preference)
First Nation/Band Name First Nation/Band Number (3 digits) (if known)
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SECTION 3: Document Requirements
A. Proof of Birth Document Original document included
Registration Number on Birth Document Province/Territory of Issuance State (USA) of Issuance
B. Name Linking Document(s)
(Provide if the name used on this application is different than the name listed on your proof of birth document)
Name (exactly as it appears on the document) Document Type
C. Supporting Identity Document(s)
Document Type Document Number Expiry Date (YYYYMMDD) (if applicable)
Name (exactly as it appears on the document)
Document Type Document Number Expiry Date (YYYYMMDD) (if applicable)
Name (exactly as it appears on the document)
Document Type Document Number Expiry Date (YYYYMMDD) (if applicable)
Name (exactly as it appears on the document)
SECTION 4: Adoption Information
(Complete this section ONLY if you were adopted as a child)
I was adopted as a child, and I believe that I have entitlement to Indian status through
(select all that apply)
My adoptive mother My adoptive father My birth mother My birth father
Adoptive Mother
Family Name Given Name(s) Date of Birth (YYYYMMDD)
Adoptive Father
Family Name Given Name(s) Date of Birth (YYYYMMDD)
Birth Mother (if known)
Family Name Given Name(s)
Birth Father (if known)
Family Name Given Name(s)
► If you believe that you are entitled to Indian status through your adoptive parent(s), complete the Family Information (section 5) with
your adoptive parents’ information.
► If you believe that you are entitled to Indian status through your birth parent(s), complete the Family Information (section 5) with your
birth parents’ information, if available.
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SECTION 5: Family Information
A. Father
Family Name
Family Name at Birth (if different) Given Name(s)
Date of Birth
(YYYYMMDD)
First Nation/Band Name
First Nation/Band (3 digits) Number or
Registration (10 digits) Number
Was the father adopted? Yes No Unknown Parent not stated on the birth document
B. Mother
Family Name Family Name at Birth (if different) Given Name(s)
Date of Birth
(YYYYMMDD)
First Nation/Band Name
First Nation/Band (3 digits) Number or
Registration (10 digits) Number
Was the mother adopted? Yes No Unknown
C. Maternal Grandparents
(Provide information up to the first person registered. For example, if your mother is registered, information on the grandparents and great-grandparents is
not required)
Family Name
Family Name at Birth
(if different)
Given Name(s)
Date of Birth
(YYYYMMDD)
First Nation/Band Name
or Registration No.
Adopted
Yes/No
Grandfather
Grandmother
Great-Grandfather (1)
Great-Grandmother (1)
Great-Grandfather (2)
Great-Grandmother (2)
D. Paternal Grandparents
(Provide information up to the first person registered. For example, if your father is registered, information on the grandparents and great-grandparents is
not required)
Family Name
Family Name at Birth
(if different)
Given Name(s)
Date of Birth
(YYYYMMDD)
First Nation/Band Name
or Registration No.
Adopted
Yes/No
Grandfather
Grandmother
Great-Grandfather (1)
Great-Grandmother (1)
Great-Grandfather (2)
Great-Grandmother (2)
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Additional Family Information (optional): List the names of other registered relatives such as brothers, sisters, aunts, uncles, cousins.
(Add separate pages if additional space is required)
SECTION 6: Photo and Signature to Appear on the Secure Certificate of Indian Status (SCIS)
► Select what applies to you.
Two (2) unaltered, identical, Canadian passport-style photographs are included SCIS not requested
► Sign your name inside the box without touching the borders. You may sign with an “X”, in syllabics or another language, as long
as this is your usual legal signature.
SECTION 7: Declaration and Signature
► Failing to sign and date the declaration will delay the processing of your application.
I solemnly declare that all statements made in this application are true, all documents provided to support this application are unaltered,
and the enclosed photographs (if requesting a Secure Certificate of Indian Status) are a true likeness of me. I have read and understand
the Notice to Applicants and the Privacy Act Statement.
If eligible, I
(Print Name)
, r
equest
to be registered in the Indian Register and, if applicable, to have
my name entered on a First Nation/Band List, as provided for under the Indian Act. I further request to have a Secure Certificate of Indian
Status issued to me (if applicable).
Signature
X
Date
(YYYYMMDD)
SECTION 8: Indian Registration Administrator (IRA)
► If an IRA assisted in completing this form, he or she must complete and sign this section.
Name
First Nation/Band Number
or Initiator Code
IRA Signature
X
Date
(YYYYMMDD)
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APPLICATION FOR REGISTRATION ON THE INDIAN REGISTER AND FOR THE SECURE CERTIFICATE OF INDIAN STATUS (Natural Resources Canada)

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Completed 17 September 2020

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