Fillable REGISTRATION AND SECURE CERTIFICATE OF INDIAN STATUS (SCIS) (Natural Resources Canada)

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REGISTRATION AND SECURE CERTIFICATE OF INDIAN STATUS (SCIS) (Natural Resources Canada)

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PROTECTED B (When Completed)
Page 1 of 2
INTER 81-010E 2009-10-19
INTER 83-169SE 2019-02-27
REGISTRATION AND SECURE CERTIFICATE OF INDIAN STATUS (SCIS)
GUARANTOR DECLARATION
GENERAL INFORMATION
A guarantor is a person who can confirm the identity of the
applicant.
Family members may act as guarantors only if they meet all the
criteria listed below.
A parent or legal guardian applying for registration or for the
Secure Certificate of Indian Status (SCIS) on behalf of a child or
dependent adult cannot act as guarantor for the child or
dependent adult.
The guarantor must perform the following tasks, as needed,
free of charge:
• Complete and sign the Guarantor Declaration form.
• Sign and date the photocopies of the front and back of the
applicant's identity documents.
• Sign and date the back of one (1) of the applicant's
Canadian passport-style photographs, and write the
following statement: "This is a true likeness of (name of
applicant or child or dependent adult)."
CRITERIA
The guarantor:
• Must be 18 years of age or older.
• Must reside in Canada or the United States.
• Must be reachable for verification by the Department.
• Must have known the applicant personally for at least two
(2) years.
Note: To know the applicant personally means that the guarantor is
able to confirm information about the applicant, such as the name,
approximate age, place of birth, physical description and some
personal history such as place of residence.
The guarantor must be someone from the following list:
• Holder of a valid SCIS (who was 16 years of age or older
when he/she applied for the card)
• Indian Registrar or Deputy Registrar
• Elected or appointed official (Band chief or councillor,
Indian registration administrator, mayor, member of
Parliament/Legislative Assembly)
• Medical professional (dentist, medical doctor, optometrist,
pharmacist, chiropractor or registered nurse)
• Judge, magistrate or police officer (First Nations; RCMP;
municipal, provincial, territorial police)
• Lawyer, notary public
• Minister of religion
• Postmaster/postmistress
• Senior university/college/school administration official and
professor/teacher
• Professional accountant
• Professional engineer
• Registered social worker or social service worker
• Military personnel (only for Regular Force members and
their dependents)
• Other occupations: visit www.canada.ca/indian-status for a
more detailed list.
If an eligible guarantor is not available, the applicant must complete the Registration and Secure Certificate of Indian Status Statutory
Declaration in Lieu of Guarantor (form 83-170E), and provide two (2) references who are not relatives.
The references:
• Must be 18 years of age or older.
• Must reside in Canada or the United States.
• Must be reachable for verification by the Department.
• Must have known the applicant personally for at least two (2) years.
Note: The Statutory Declaration in Lieu of Guarantor (form 83-170E) must be completed and signed before a Commissioner for Oaths,
notary public or lawyer.
PROTECTED B (When Completed)
Page 2 of 2
INTER 81-010E 2009-10-19
INTER 83-169SE 2019-02-27
REGISTRATION AND SECURE CERTIFICATE OF INDIAN STATUS (SCIS)
GUARANTOR DECLARATION
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 on 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.
► Complete this form online, or write in block letters using black or dark blue ink.
Applicant Information
► For the purposes of this form, the applicant is the adult (16 years of age or older) applying for registration and/or for the Secure
Certificate of Indian Status (SCIS), or the parent/legal guardian applying for a child (15 years of age or younger) or dependent adult.
Family Name
Given Name(s)
Alias / Cultural Name (if applicable)
Date of Birth (YYYYMMDD)
Registration Number (10 digits) (if applicable)
I certify that I am the person (applicant) named above
Signature of Applicant
X
Date (YYYYMMDD)
Name of Child/Dependent Adult (if applicable)
Family Name
Given Name(s)
Guarantor Information and Declaration
Family Name
Given Name(s)
Permanent Address
Number, Street, Apartment, P.O. Box
City/Town
Province/Territory (Canada) State (USA) Postal/ZIP Code
SCIS Serial Number (on the back of the card) Occupation (if guarantor does not have an SCIS)
Applicant known for years (minimum 2 years)
Telephone Number (Daytime)
Name of Firm/Organization (if applicable)
Instructions for guarantor: As needed, you must sign and date the photocopies of the front and back of the documents that support the
applicant's identity. You must also sign, date and write the statement “This is a true likeness of (name of applicant or child or dependent adult)”
on the back of one (1) of the two photographs.
I solemnly declare that I am at least 18 years of age and have known the applicant named above personally for at least two (2) years. I have
signed and dated the back of one photo and confirm that the image is a true likeness of the applicant, child or dependent adult, (if a Secure
Certificate of Indian Status is requested). I have signed a photocopy of the front and back of each document to support the applicant's identity and
confirm that I have seen the original document(s). I understand that any false or misleading statement relating to this form and any document in
support of the application, including the concealment of any material fact, may be grounds for criminal prosecution.
Signature of Guarantor
X
Date (YYYYMMDD)
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Completed 15 April 2021

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