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PROTECTED
B (WhenCompleted)
SECURE CERTIFICATE OF INDIAN STATUS (SCIS)
GUARANTOR DECLARATION
General Information
Aguarantorisapersonotherthanyourselfwhoconfirms
youridentityandperformstherequiredtasksfreeof
charge.
Your guarantor:
•
•
must be18yearsofageorolder;
must haveknownyoupersonallyforatleast TWO (2)
years. To know an applicant personally means that
the guarantor is able to confirm aspects of your
personal attributes such as name, approximate
age, place of birth, physical description and some
personal history such as place of residence;
•
must beaccessibleforIndigenousandNorthern
AffairsCanada(INAC)tocontact;and
•
must beresidinginCanadaortheUnitedStates.
Your guarantor must be someone from the following
list:
•
•
•
IndianRegistraroranIndianRegistryAdministrator;
•
Dentist,medicaldoctor,optometrist,pharmacistor
chiropractor;
•
Judge,magistrateorpoliceofficer(FirstNations,
municipal,provincial,territorialorRCMP);
•
•
•
Lawyer;
•
•
•
•
CommissionerforOaths;
•
•
•
•
Senioradministratororprofessorinacommunity
collegeoruniversity;
Registeredsocialworker;
Veterinarian.
Family members as guarantors:
Afamilymembermayactasguarantorifhe/sheis
18yearsofageorolder,residinginCanadaortheUnited
States,isavailabletobecontactedbyINACfor
verification,AND meetstheguarantorcriteria.
Please note that a parent or legal guardian applying
for a SCIS for the child or dependent adult cannot also
act as a guarantor for the child or dependent adult.
When a guarantor is being used for mail-in
applications (in-Canada only) your guarantor must:
•
CompleteandsigntheGuarantorDeclaration
(83-111E);
•
Write“This is a true likeness of (the name of
applicant/child/dependent adult)”onthebackof
ONE (1) ofthetwoup-to-datepassportstyle
photographs.Theguarantormustalsosignand
datethebackofthephotograph;and
•
Signanddateaphotocopyofthefrontandbackof
thedocumentsthatsupporttheapplicant’sidentity.
ElectedChieforCouncillorofthebandtowhichthe
applicantbelongs;
Mayor;
Professionalengineer;
When a guarantor is being used in lieu of ID
(in-Canada only) your guarantor must:
Ministerofareligionauthorizedunderaprovincial,
territoriallawtoperformmarriages;
•
CompleteandsigntheGuarantorDeclaration
(83-111E);and
Notarypublic;
•
Write“This is a true likeness of (the name of
applicant/child/dependent adult)”onthebackof
ONE (1) ofthetwoup-to-datepassportstyle
photographs.Theguarantormustalsosignand
datethebackofthephotograph.
Postmaster/Postmistress;
Principalofaprimaryorsecondaryschool;
Professionalaccountant;
IfyoudonothaveaccesstoaneligibleguarantorwhohasknownyouforatleastTWO (2) years,youmust completea
StatutoryDeclarationinLieuofGuarantor(83-112E)andprovide TWO (2) referenceswhoarenotrelatives.Thisformmust
becompletedbeforeaCommissionerforOaths,NotaryPublicorLawyer.
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PROTECTED
B (WhenCompleted)
SECURE CERTIFICATE OF INDIAN STATUS (SCIS)
GUARANTOR DECLARATION
Privacy Act Statement
PersonalinformationprovidedinthisdocumentiscollectedbyIndigenousandNorthernAffairsCanada(INAC)undertheauthorityofthe
Indian Act.IndividualshavetherighttotheprotectionofandaccesstotheirpersonalinformationunderthePrivacy Act.Theinformation
provided is voluntary. Failure to provide sufficient information may render the application invalid or may result in processing delays.
Informationprovidedissubjecttoroutineverifications,includingverificationsagainsttheIndianRegister.INACmay,forthepurposeof
receiving applications, collect personal information from Indian RegistryAdministrators. In the performance of these duties, personal
informationwillbeprocessedandusedinaccordancewiththeprovisionsofthePrivacy Act.Furtherdetailsonthecollection,useand
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 AND GUARANTORS
TheSCISremainsatalltimesthepropertyoftheGovernmentofCanadaandmustonlybeusedbythepersoninwhose
nameitisissued.Anyfalseormisleadingstatementsonthisformorrelatingtoanydocumentinsupportofthisapplication,
includingconcealmentofanymaterialfact,sellingaSCISorpermittinganyotherindividualoragencytouseyourSCIS
mayleadtocriminalprosecutionandiscauseforrevocationoftheSCISandrefusaloffutureSCISissuance.
Applicant Information (Completeinblocklettersusingblackordarkblueink)
1. Applicant’sFamilyName(LastName)
2. Applicant’sGivenName(s)
Child’s/DependentAdult’sFamilyName(LastName)(tobe Child’s/DependentAdult’sGivenName(tobecompleted
completedonlyifGuarantorDeclarationisinsupportofa
onlyifGuarantorDeclarationisinsupportofa
Child/DependentAdultApplication(83-131E))
Child/DependentAdultApplication(83-131E))
3. IndianRegistrationNo.
(ForAdultapplication,includeapplicant'sRegistration
No.,forchild’sordependentadult’sapplications,include
Child’s/DependentAdult’sRegistrationNo.)
4. I certify that I am the named individual above (and, as
necessary, the parent or legal guardian of the child or
dependent adult named above).
SignatureofApplicant
Date(YYYYMMDD)
X
Guarantor Information and Declaration
1. Guarantor’sFamilyName(LastName)
3. AddressofPermanentResidence
Number/Street/Apartment/P.O.Box
2. Guarantor’sGivenName(s)
City/Town
Province/Territory/State Postal/ZIPCode
4. Guarantor’sOccupation(SeelistonPage1)
5. NameofFirm/Organization
6. TelephoneNo.(Daytime)
7. Ihaveknowntheapplicantfor
()
_____________years(minimumof2years)
I solemnly declare that I am at least 18 years of age and confirm that I have known the applicant identified above
personally for at least TWO (2) years. I declare that any false or misleading statements on this Guarantor Declaration or
relating to any document in support of this application, including concealment of any material fact, may lead to refusal or
revocation of a SCIS and be grounds for criminal prosecution.
SignatureofGuarantor
Date(YYYYMMDD)
X
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