Assessment of Matrimonial Real Property and Statutory Declaration

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ASSESSMENT OF MATRIMONIAL REAL PROPERTY AND STATUTORY DECLARATION

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Concerning real property transactions under the Indian Act and the rights of Spouses and Common-law partners under the

Provisional Federal Rules of the Family Homes on Reserves and Matrimonial Interests or Rights Act.

Privacy Act Statement

This statement explains the purposes and use of your personal information. Only information needed to respond to program requirements will be

requested. Collection and use of personal information is in accordance with the Privacy Act. In some cases, information may be disclosed without your

consent pursuant to subsection 8(2) of the Privacy Act. The collection and use of your personal information for this Statutory Declaration is authorized by

sections 21, 24, 28(2), 53(1)(b) of the Indian Act http://laws-lois.justice.gc.ca/eng/acts/i-5/ and sections 15-18, 20, 31-32 and 50 of the Family Homes on

Reserves and Matrimonial Interests or Rights Act http://laws-lois.justice.gc.ca/eng/acts/F-1.2/ and is required for your participation. We will use your

personal information, your contact information, for the processing of the form. We share the personal information you give us with Bands (First Nation

Governments) for whom INAC tracks this. The information collected is described in Personal Information Bank "Monitoring and Compliance of Reserve

Land Instruments", INAC PPU 096, detailed at http://www.aadnc-aandc.gc.ca/eng/1100100011039/1100100011040, will be retained for a period of 30

years after the last administrative action and then transferred to Library and Archives Canada (LAC) as archival records. As stated in the Privacy Act, you

have the right to access your personal information and request changes to incorrect information. Contact our office (toll-free) at 1-800-567-9604 to notify us

about incorrect information. For more information on privacy issues and the Privacy Act in general, you can consult the Privacy Commissioner at 1 (800)

282-1376.

Important Note

If you are an Executor of a will or an Administrator of an estate wanting to distribute the estate of a deceased individual who held an

interest on reserve, you do not have to complete this form. Please complete the form Statutory Declaration of Executor of a will or

Administrator of an estate.

This document is to be completed by individuals and corporations that are solely owned by individuals wanting to effect the following real

property transactions:

• Leases pursuant to s. 58 of the Indian Act

• Assignments pursuant to s. 53(1)(B) and s. 58 of the Indian Act

• Mortgages requiring Ministerial approval

• Transfers

• Permits s. 28(2) (Locatee)

• Sub-Leases requiring Ministerial approval

Note: For solely owned corporations this form is to be completed by the owner as him or herself.

Section A - Legal Land Description

Province/Territory

Reserve Name:

Legal Land Description

Section B - Statutory Declaration (made pursuant to s. 41 of the Canada Evidence Act, R.S. 1985, c. C-5)

(Name)

(Indian registration Number, if applicable)

, of

(Name of city, town, etc.)

in the Province or Territory of

SOLEMNLY DECLARE THAT

(Select the applicable)

1. I am, or my Spouse or Common-law partner is, a First Nation member or Indian.

Yes (proceed to statement 2) No (sign declaration)

2. I am married or in a common law relationship.

Yes (proceed to statement 3) No (proceed to statement 6)

3. My family home is situated on the Property.

Yes (proceed to statement 4) No (proceed to statement 6)

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4. My Spouse or Common-law partner and I have entered into a legally binding domestic contract (e.g., separation agreement, co-

habitation agreement) in which my Spouse or Common-law partner has specifically released all of his/her rights to the Property under the

FHRMIRA.

Yes (proceed to statement 6) No (proceed to statement 5)

5. I have obtained a court order under s. 15(6) of the FHRMIRA authorizing me to dispose of or encumber the Property without the

consent of my Spouse or Common-law partner.

Yes (attach a copy of the court order) (proceed to statement 6)

No (your Spouse or Common-law partner must complete the

Statutory Declaration of Spouse or Common-law partner )

(proceed to statement 6)

6. A court order (other than a court order referred to in statement 5) has been made under the FHRMIRA with respect to the Property.

Yes (attach a copy of the court order(s) and sign below) No (sign below)

AND I MAKE this solemn declaration conscientiously believing it to be true, and knowing that it is of the same force and effect as if made

under oath.

DECLARED BEFORE ME at

(City, Town, etc.)

in the

(Province or Territory)

this

(Day)

(Month)

(Year)

(Signature of declarant)

A Commissioner, etc.