INTER 83-174E 2020-12-24 (A)
PROTECTED B (when completed)
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INTER 81-010E 2009-10-19
STATUTORY DECLARATION FOR BIOLOGICAL PARENTS AFFIRMING PARENTAGE
(when a parent's name is not listed on their child's proof of birth document)
Privacy Statement
Personal information is collected, used and disclosed by Indigenous Services Canada in accordance with the Privacy Act (https://laws-lois.justice.gc.ca/
eng/acts/P-21/index.html). Only information needed to administer the Indian Registration and the Secure Certificate of Indian Status programs is collected.
The authority to collect and use personal information is derived from the Indian Act (https://laws-lois.justice.gc.ca/eng/acts/i-5/). The information collected is
used to determine entitlement to registration on the Indian Register and membership in a First Nation whose 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 to those who are registered. The description
of this personal information collection (AANDC PPU 110, AANDC PPU 220) is available at Info Source (https://www.aandc-aadnc.gc.ca/
eng/1353081939455/1353082011520). You have the right to access and request corrections to your personal information by contacting the department’s
Privacy Coordinator at 819-997-8277. For more information on privacy issues, complaints and the Privacy Act in general, you may consult the Privacy
Commissioner at 1-800-282-1376.
Instructions
► Under the Indian Act, eligibility for Indian status is based on the degree of descent from ancestors who are registered or entitled to be
registered.
► The Declaration can be used by one or both biological parents to affirm parentage when the name of a parent is not listed on their
child's proof of birth document (usually, a birth certificate).
Note: The Declaration does not replace the proof of birth document that must be submitted with an application for registration.
Note: The Declaration is not necessary if you have a court order declaring biological parentage.
► Parents can make a declaration using the same form or separate forms.
► The Declaration must be signed before a person who is authorized by law to administer oaths and declarations, for example, a
commissioner for oaths or for taking affidavits, a lawyer, a notary or a justice of the peace.
► To obtain forms or additional information, visit www.canada.ca/indian-status or call 1-800-567-9604.
► Complete the form on-screen or write in block letters using black or dark blue ink.
SECTION 1: Biological parents
Family name
Given names
Family name at birth (if different from name above)
Date of birth (YYYYMMDD) Telephone number (daytime)
Registration number (10 digits; if applicable)
City
Mailing address (number, street, apartment, P.O. box)
State (USA) Postal/ZIP code
Parent
Email address
Province/Territory (Canada)
Family name
Given names
Family name at birth (if different from name above)
Date of birth (YYYYMMDD) Telephone number (daytime)
Registration number (10 digits; if applicable)
City
Mailing address (number, street, apartment, P.O. box)
Province/Territory (Canada)
State (USA) Postal/ZIP code
Other parent
Email address
SECTION 2: Person on whose behalf a declaration is made (child)
Family name Given names
Family name at birth (if different from name above)
Registration number (10 digits; if applicable)
Telephone number (daytime) Telephone number (other)
Date of birth (YYYYMMDD)
