Form INTER83-155E "Statutory Declaration of Executor of a Will or Administrator of an Estate Who Is Also the Surviving Spouse or Common-Law Partner" - Canada

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Download Form INTER83-155E "Statutory Declaration of Executor of a Will or Administrator of an Estate Who Is Also the Surviving Spouse or Common-Law Partner" - Canada

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PROTECTED B (When Completed)
Page 1 of 2
STATUTORY DECLARATION OF EXECUTOR OF A WILL OR ADMINISTRATOR OF AN
ESTATE WHO IS ALSO THE SURVIVING SPOUSE OR COMMON-LAW PARTNER
Concerning the devise or descent of land under the Indian Act and the rights of Survivors 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 42-50.1 of the Indian Act
http://laws-lois.justice.gc.ca/eng/acts/i-5/
and sections 21, 36, 38(1), 39 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
Indigenous and Northern Affairs Canada (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
DO NOT complete this form if the person whose estate you are administering died on or before December 15, 2014.
This form must be completed by the Executor or Administrator, who is also the surviving spouse or common-law partner, wanting to
distribute the estate of a deceased individual who died after December 15, 2014 and held an interest on reserve, in order to demonstrate
compliance with s. 38(1) of the Family Homes on Reserves and Matrimonial Interests or Rights Act (FHRMIRA).
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)
I,
, of
in the Province or Territory of
(Name of Executor/Administrator)
(Name of city, town, etc.)
SOLEMNLY DECLARE THAT:
1. I am the Executor or Administrator of the estate of
.
(Name of Deceased and Indian Registration Number, if applicable)
2. The deceased died on
. A certified copy of the death certificate is attached, unless previously provided to
(Date
)
(YYYYMMDD)
Indigenous and Northern Affairs. If you were appointed to the deceased's estate by Indigenous and Northern Affairs Canada, this
document is not required.
3. The deceased held the Property on the date of death.
4. I am the
of the deceased.
(Surviving Spouse or Surviving Common-Law Partner)
5. As the Executor or Administrator of the deceased's estate, I am applying to
the Property.
(Transfer, Lease, etc.)
INTER 83-155E 2017-08-31 (A)
PROTECTED B (When Completed)
Page 1 of 2
STATUTORY DECLARATION OF EXECUTOR OF A WILL OR ADMINISTRATOR OF AN
ESTATE WHO IS ALSO THE SURVIVING SPOUSE OR COMMON-LAW PARTNER
Concerning the devise or descent of land under the Indian Act and the rights of Survivors 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 42-50.1 of the Indian Act
http://laws-lois.justice.gc.ca/eng/acts/i-5/
and sections 21, 36, 38(1), 39 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
Indigenous and Northern Affairs Canada (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
DO NOT complete this form if the person whose estate you are administering died on or before December 15, 2014.
This form must be completed by the Executor or Administrator, who is also the surviving spouse or common-law partner, wanting to
distribute the estate of a deceased individual who died after December 15, 2014 and held an interest on reserve, in order to demonstrate
compliance with s. 38(1) of the Family Homes on Reserves and Matrimonial Interests or Rights Act (FHRMIRA).
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)
I,
, of
in the Province or Territory of
(Name of Executor/Administrator)
(Name of city, town, etc.)
SOLEMNLY DECLARE THAT:
1. I am the Executor or Administrator of the estate of
.
(Name of Deceased and Indian Registration Number, if applicable)
2. The deceased died on
. A certified copy of the death certificate is attached, unless previously provided to
(Date
)
(YYYYMMDD)
Indigenous and Northern Affairs. If you were appointed to the deceased's estate by Indigenous and Northern Affairs Canada, this
document is not required.
3. The deceased held the Property on the date of death.
4. I am the
of the deceased.
(Surviving Spouse or Surviving Common-Law Partner)
5. As the Executor or Administrator of the deceased's estate, I am applying to
the Property.
(Transfer, Lease, etc.)
INTER 83-155E 2017-08-31 (A)
PROTECTED B (When Completed)
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Check all that apply
6. To the best of my knowledge, information and belief, I am the only Survivor of the deceased.
Yes
No. The other survivor must complete a Statutory Declaration of Surviving Spouse or Common-Law Partner.
7A.
Consent of the Survivor is required under s. 38(1) of the FHRMIRA, and I hereby give my free and informed consent to the
of the Property.
(Transfer, lease, etc.)
Consent of the Survivor is not required under s. 38(1) of the FHRMIRA because I made a court application under s. 36 of the
7B.
FHRMIRA and that application has been finally disposed of. This transfer is consistent with that court resolution. A copy of the
court order is attached.
8. A court order (other than a court order referred to above, if any) has been made under the FHRMIRA with respect to the Property.
Yes (attach a copy of the court order(s))
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
, this
in the
of
,
.
(City, Town, etc.)
(Day)
(Month)
(Year)
(Province or Territory)
A Commissioner, etc.
(Signature of Declarant)
INTER 83-155E 2017-08-31 (A)
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