Declaration Guarantor Form – Fill Out and Use This PDF

SECURE CERTIFICATE OF INDIAN STATUS (SCIS)

STATUTORY DECLARATION

IN LIEU OF GUARANTOR

Privacy Act Statement

Personal information provided in this document is collected by Aboriginal Affairs and Northern Development Canada (AANDC) under the authority of the Indian Act. Individuals have the right to the protection of and access to their personal information under the Privacy Act. The information provided is voluntary. Failure to provide sufficient information may render the application invalid or may result in processing delays. Information provided is subject to routine verifications, including verifications against the Indian Register. AANDC may, for the purpose of receiving applications, collect personal information from Indian Registry Administrators. Furthermore, personal information will be disclosed to a third party for the purpose of printing the SCIS. In the performance of these duties, personal information will be processed and used in accordance with the provisions of the Privacy Act. Further details on the collection, use and disclosure of personal information are described under the Personal Information Bank INA PPU 110, which is detailed at www.infosource.gc.ca.

NOTICE TO ALL APPLICANTS

The 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 statements on this form or relating to any document in support of this application, including concealment of any material fact, selling an SCIS or permitting any other individual or agency to use your SCIS may lead to criminal prosecution and is cause for revocation of the SCIS and refusal of future SCIS.

Important: This form must be completed and signed before a Commissioner for Oaths, Notary Public or Lawyer.

AApplicant – Personal Information (Complete in block letters using black or dark blue ink)

Addresses (List your addresses in the past FIVE (5) years beginning with the most current)

BReferences

I have personally sought agreement and consent from the TWO (2) following persons, who are not my relatives and have known me for at least TWO (2) years, to be contacted to confirm my identity:

One reference must sign one of the passport style photographs on the reverse side with the statement “This image is a true likeness of (name of applicant/child/dependent adult)”. BOTH references are required to sign and date a copy of the front and back of the applicant's identity documents.

C Declaration of Applicant

For mail-in applications only: I have presented copies (both sides) of my identity documents which together bear my name, photograph and signature and passport style photographs, to the references above for signature.

Declaration: I solemnly declare that I am unable to obtain an eligible guarantor as defined in the Guarantor Declaration (83-111E), the statements made in this declaration are true and the photos enclosed are a true likeness of me or the child/dependent adult.