PROTECTED B (When Completed)
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INTER 81-010E 2009-10-19
INTER 83-172SE 2019-03-07
SECURE CERTIFICATE OF INDIAN STATUS (SCIS)
APPLICATION FOR ALREADY REGISTERED PERSONS
ADULTS (16 YEARS OF AGE OR OLDER), CHILDREN (15 YEARS OF AGE OR YOUNGER) AND DEPENDENT ADULTS
Privacy Act Statement
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 issue a Secure Certificate of Indian Status to registered persons. 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). 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, you can consult the Privacy Commissioner at 1-800-282-1376.
Complete this form online, or write in block letters using black or dark blue ink.
Instructions (83-172IE) to complete the form : visit www.canada.ca/Indian-status or call 1-800-567-9604.
SCIS is the abbreviation for Secure Certificate of Indian Status.
Reason for Application (Select ONE option)
First SCIS Renewal
Replacement (lost, stolen, damaged SCIS) Replacement (changes to personal information)
SECTION 1: Information on Person to be Issued an SCIS
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)
Registration Number (10 digits) First Nation/Band Name
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: Parent/Legal Guardian Information (Complete this section ONLY if applying for a child or dependent adult.)
Family Name Given Name(s)
Family Name at Birth (if different from above)
Registration Number (10 digits) (if applicable) Date of Birth (YYYYMMDD)
Relationship to Child/Dependent Adult:
Parent Custodial Parent Legal Guardian Other (Specify)
If applying for a child: Are there separation agreements, court orders or legal proceedings pertaining to the custody of the child?
No Yes If yes, provide photocopies of all legal documents.
If applying for a dependent adult, include a photocopy of the Order of Guardianship.
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INTER 81-010E 2009-10-19
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SECTION 3: Identity Document(s) for Adult Applicant or Parent/Legal Guardian (refer to the instructions)
Document Type Document Number
Expiry Date (YYYYMMDD)
(if applicable)
Name (as it appears on the document)
SECTION 4: Name-Linking Document(s) (refer to the instructions)
Name (exactly as it appears on the document) Document Type
SECTION 5: Photo and Signature to Appear on the Secure Certificate of Indian Status (SCIS)
Include two (2) unaltered, identical, Canadian passport-style photographs (refer to the instructions for photos).
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 signature. A signature is not required if the SCIS is for a child (15 years of age or younger) or dependent
adult.
SECTION 6: Declaration and Signature
Failing to sign and date the declaration will delay the processing of your application.
Notice to Applicants: 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
person or agency, is cause to revoke or refuse to issue an SCIS, and may lead to criminal prosecution.
Declaration: 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 are a true likeness of me or the child / dependent adult. I have read and understand the
Notice to Applicants and the Privacy Act Statement.
I request that
(Print Name of Adult, Dependent Adult or Child)
, if eligible, be issued a Secure Certificate of Indian Status.
If applying to replace a lost, stolen, damaged or destroyed SCIS: I declare that I have not given my Secure Certificate of Indian Status
(SCIS) to another person or disposed of it in an unauthorized manner. I understand that an SCIS reported lost, stolen, damaged or
destroyed is no longer valid and can no longer be used. Should I regain possession of my SCIS, I understand that I am to destroy it
immediately.
Signature of Adult Applicant (16 years of age or older) or Parent/Legal Guardian
X
Date
(YYYYMMDD)
SECTION 7: 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)
click to sign
signature
click to edit
click to sign
signature
click to edit
click to sign
signature
click to edit
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