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INTER 81-010E 2009-10-19
INTER 83-172SE 2019-03-07_v2
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)
Gender: M (male) F (female) X (another gender) 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 copies of all legal documents.
► If applying for a dependent adult, include a copy of the Order of Guardianship.