INTER 83-175E 2020-12-24 (A)
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INTER 81-010E 2009-10-19
Privacy Statement
Personal information is collected, used and disclosed by Indigenous Services Canada in accordance with the Privacy Act (
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 ( 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 (
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.
The Declaration can be used to provide information that could help establish a person’s entitlement to registration (Indian status) in
situations where a parent, grandparent or other ancestor is unknown or unstated.
The Declaration can be completed by the person applying for Indian status or requesting changes to parental information on the
Indian Register; or by any other person, including family members, First Nation/Band officials and Elders. The person making the
declaration may be contacted to clarify information.
Note: The Declaration does not replace the proof of birth document. An original proof of birth document must be submitted with an
application for registration.
Any document to help establish parentage can be submitted with the form, for example, an amended proof of birth document listing
the parents’ names; statutory declarations; court documents; census, church, school and hospital records; and band council
The Declaration must be signed before a person who is authorized by law to administer oaths, affirmations and declarations,
for example, a commissioner for oaths, a commissioner for taking affidavits, a lawyer, a notary or a justice of the peace.
To obtain forms or additional information, visit or call 1-800-567-9604.
Complete the form on-screen or write in block letters using black or dark blue ink.
SECTION 1: Person on whose behalf a declaration is made
Family Name Given Names
Family Name at Birth (if different from name above)
Date of Birth (YYYYMMDD)
Telephone Number (daytime) Telephone Number (other) Registration Number (10 digits; if applicable)
SECTION 2: Person making the declaration (if different from person above)
Family Name Given Names
First Nation/Band Name (if applicable) Registration Number (10 digits; if applicable)
Telephone Number (daytime) Telephone Number (other) Email Address
Mailing Address (number, street, apartment, P.O. box)
Province/Territory (Canada)
State (USA) Postal/ZIP Code
Relationship to person on whose behalf a declaration is made
Elder Relative
First Nation/Band Official Other
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INTER 83-175E 2020-12-24 (A)
SECTION 3: Declaration
• Provide any information that could help establish the person’s entitlement to registration (Indian status).
• Attach additional pages if more space is needed and initial each attached page.
I make the following solemn declaration conscientiously believing it to be true and knowing that it is of the same force and effect as if made
under oath:
Source of Information (explain how you came to know the information provided in your declaration)
SECTION 4: Person authorized to administer oaths
Commissioner for Oaths/Affidavits Notary/Notary Public Lawyer
Family Name Given Names
Name of Business/Organization (if applicable) Telephone Number (daytime) Telephone Number (other)
Email Address Mailing Address (number, street, unit, P.O. box)
Province/Territory (Canada)
State (USA) Postal/ZIP Code
Number of pages attached to form (if any) Note : Each page must be initialed by you and the declarant.
Declarant's Name (family name, given names)
Declarant's Signature
Declared before me:
Signature of person authorized to administer oaths
(If applicable, add your seal/stamp and information such as your licence
number, commission number and expiry date.)