ISC ANNUITY PAYMENTS FORM

The collection, use and disclosure of personal information by the Treaty Annuities Program is authorized under the Indian Act (https://laws- lois.justice.gc.ca/eng/acts/i-5/), and is in accordance with the requirements of the Privacy Act (https://laws-lois.justice.gc.ca/eng/acts/P-21/index.html). Information collected will be used exclusively for the purpose of administration for the payment of treaty annuities. Personal information will be retained pursuant to the Privacy Act and its Regulations. The collection of information is described in the Treaty Annuities Personal Information Banks PSU 931 and AANDC PPU-009 located in the departmental Info Source publication, online at Info Source (https://www.sac-isc.gc.ca/eng/1353081939455). Individuals have the right to the protection of, access to and request the correction of their personal information under the Privacy Act. If you require clarification concerning the Privacy Statement, please contact the Departmental Access to Information and Privacy Office at 1-819-997-8277 or by email at upvp- ppu@sac-isc.gc.ca. For more information on privacy issues, your right to file a complaint and the Privacy Act in general, you can consult the Privacy Commissioner at 1-800-282-1376.

• This form must be completed and submitted each time an annuity is requested, and must be accompanied by all required supporting documents and information.
• By completing and submitting this form, the total amount of the annuity owed to the individuals (for whom information is provided below) will be disbursed, including any arrears.
• Required documents: A photocopy of both sides of a valid Certificate of Indian Status (CIS) card or Secure Certificate of Indian Status (SCIS) card (also known as ‘registration’ or ‘status’ cards) for all whom treaty annuity funds are being requested (including dependent children and/or guardianship).
• If you do not have a valid CIS or SCIS card available, any other valid government issued identification which has your signature is acceptable. A photocopy of both sides must be included with the form.
• If requesting payment on behalf of minors in your custody for whom you are the legal guardian, provide a photocopy of proof of guardianship.
• A single lump-sum payment of the combined annuity amounts owed to all individuals listed on this form will be issued to applicant.
• Email submission: If submitting via email, photographs of the signed form, cards and any other identification and documents are accepted if attached to the email. All information is mandatory except as noted.

    ▶ Complete sections 1 to 5.

    1 - First Nation region

    QuebecOntarioManitobaSaskatchewan

    2 - Applicant mailing address and contact information (all information must be current.)










    3 - Treaty annuitant information (individuals for whom treaty annuity funds are being requested)

    Family name

    Given name

    Date of birth
    (YYYYMMDD)

    First Nation

    Registration no.

    [-]

    [-]

    [-]

    Note: If you need more rows, please continue on a separate sheet

    4 - Payment method (choose ONE of the following payment options)

    4(A) Cheque (payment will be mailed via cheque to the address noted in page 1, section 2)4(B) Direct deposit (Canadian bank accounts only) - Proceed with method (1) or (2) below

    4(A) Cheque method

    Complete section 2

    OR

    4(B) Direct deposit method

    (1) Submit a personal cashier cheque marked VOID

    Note: Your online banking may have a printable direct deposit form which you may include instead of a void cheque. Inquire with your financial institution for details.

    (2) The financial institution must complete the banking information below.

    (3) An amount of $2.01 will be deposited in your account in order to confirm the banking information

    Please confirm the receipt of the deposit at the following address: testdirect-test@sac-isc.gc.ca

    Banking information (completed by financial institution)

    Transit number

    Institution number

    Bank stamp

    Account number

    Financial institution name

    Account holder name

    Joint account holder name (if applicable)

    Checklist (ensure all sections have been properly completed before submitting)

    Section 1: Region location is selected

    Section 2: Each individual treaty annuitant is correctly listed

    Section 3: Applicant contact information is provided

    Section 4: The payment method is chosen

    5 - Authorization (completed by all applicants; to be signed ONLY once Sections 1 to 4 are completed.)

    ► If the bank account identified in 4(B) is a joint account, BOTH account holders MUST sign this form.

    ► I, the undersigned, request that any treaty annuity funds which are payable to me and/or the minor children in my care and custody whom I have listed on this form, are to be sent to me using the information above. By signing below I authorize consent for the collection of personal information for the administration for the payment of treaty annuities.