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STATUTORY DECLARATION IN LIEU OF GUARANTOR
Registration and Secure Certificate of Indian Status (SCIS)
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/). 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 membership 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 (ISC PPU 110, ISC PPU 220) is available at Info Source (https://www.sac-isc.gc.ca/
eng/1639748667069/1639748703555).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 Office of the
Privacy Commissioner of Canada at 1-800-282-1376.
Instructions
► If unable to find an eligible guarantor as defined in the Guarantor Declaration form (83-169E), the applicant must
provide 2 references and complete the Statutory Declaration in lieu of Guarantor form (83-170E).
► The Declaration must be signed by the applicant in the presence of a person 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.
► Complete the form on-screen or write in block letters using black or dark blue ink.
SECTION 1: Applicant
The applicant is the person (16 or older) applying for registration or for the Secure Certificate of Indian Status OR the parent/legal guardian
applying for a child (15 or younger) or dependent adult.
Family name Given names
Family name at birth (if different from name above) Alias/Cultural name (if applicable)
Date of birth (YYYYMMDD)
Registration number (10 digits) (if applicable)
Addresses where the applicant has lived in the last 5 years, beginning with the current address:
Number, Street, Apartment, City, Province/Territory/State Postal/ZIP code
From
(YYYYMM)
To
(YYYYMM)
Occupations in the last 5 years, beginning with the most recent (select all that apply):
Studying Employed Other
(specify)
Employer/School/Other Address Telephone number
Field of employment or
studies
From
(YYYYMM)
To
(YYYYMM)
Clear Data
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SECTION 2: Child/Dependent adult (if applicable)
Complete this section if the Declaration supports a child’s or dependent adult’s application for registration or for the Secure Certificate of
Indian Status.
Family name Given names
SECTION 3: References
Provide 2 references. The persons named as references must meet the following criteria: 1) be at least 18 years of age; 2) have known the
applicant personally for at least 2 years; 3) not be a relative; and, 4) be available to confirm information about the applicant if contacted by
Indigenous Services Canada.
One reference must perform the following tasks free of charge: 1) sign, date and write the name of the applicant (or the name of the child
or dependent adult) on the back of one printed photo or digital photo using the SCIS Photo App; and 2) sign and date each copy of the
front and back of the applicant’s identification documents.
1
Family name Given names
Date of birth (YYYYMMDD)
Telephone number (daytime)
Telephone number (other)
Email address
Relationship to applicant
Has known the applicant for
years (minimum 2 years)
2
Family name Given names
Date of birth (YYYYMMDD)
Telephone number (daytime) Telephone number (other)
Email address
Relationship to applicant
Has known the applicant for
years (minimum 2 years)
SECTION 4: To be completed by person authorized to administer oaths
Commissioner for Oaths/Affidavits LawyerNotary/Notary Public
Other
(specify)
Family name Given names
Business/Organization name (if applicable) Telephone number (daytime) Telephone number (other)
Email address Mailing address (number, street, unit, P.O. box)
City
Country
Province/Territory/State
Postal/ZIP code
SECTION 5: Declaration of applicant and signatures
Declaration: I solemnly declare that I am unable to find an eligible guarantor as defined in the Guarantor Declaration form (83-169E). The
persons named as references are at least 18 years of age, have known me for at least 2 years and are not relatives. 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.
Applicant name (family name, given names)
Applicant signature
►
Declared before the person
authorized to administer oaths:
Date (YYYYMMDD)
City Province/Territory/State
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.)
