Settlement Form – ERFN Registry

To ensure the efficient distribution of your Per Capita Payment, please complete the following information and submit this form. The English River First Nation Registry Department will be the first point of contact for all Adult Eligible Members (18 years of age or older) in the Per Capita Payment process.

For assistance in completing your form or to book an appointment to complete your form in-person please contact the Registry Department by calling 306-396-2055.

Beneficiary Information

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region Postal Code Country

Tax Residence(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Tax residence refers to the province or state you reside in when you file your tax returns. If you reside permanently outside of Canada and are not using a Canadian account, CIBC Trust recommends you consult with your tax advisor regarding reporting requirements in your jurisdiction. The payment will be settlement capital in CANADA, but there could be foreign tax reporting consequences.

Phone(Required)

Email(Required)

Status #(Required)

Your 10-digit status number

Date of Birth(Required)

Eligibility

Eligibility to the per capita payment in accordance with the 2023 EFN Trust Agreement for adults will be verified by the English River First Nation Registry Department prior to processing payment.

For questions related to eligibility, please contact cowsploughs@creative-fire.com.

Do you reside on either the Patuanak or La Plonge reserves?(Required)

Yes

Please attach a copy of ONE (1) piece of VALID, not EXPIRED identification.

Please attach a copy of TWO (2) pieces of VALID, not EXPIRED identification.

Identification proof (FRONT OF ID)(Required)

Identification proof (BACK OF ID)(Required)

Identification proof (2) (FRONT OF ID)(Required)

Identification proof (2) (BACK OF ID)(Required)

Verification Letter from the Registry Department (optional)

Payment Information

Preferred Payment Method(Required)

Electronic Fund Transfer (EFT) – Recommended (no cost and immediate)

Wire Transfer (out of country) – ($15 charge for each wire sent to a non-CIBC account)

Cheque (sent to English River First Nation office for you to pick up, or can be mailed to you)

For EFTs and Wire Transfers please complete the information below and attach a void cheque or a copy of your information from Online Banking for verification purposes.

Name of Bank:(Required)

Address of Bank(Required)

Transit #(Required)

Institution #(Required)

Name on Account(Required)

(account must have your name on it)

Account #(Required)

Swift/Business Identifier Code or American Bankers Association (ABA) transit routing number

Only for international wire transfers

Take a photo of a void cheque (optional)

Notes: English River First Nation and CIBC Indigenous Trust assumes no responsibility for the unsuccessful transfer of funds if incorrect information is provided. The foreign exchange rate established by the processing bank will be used, without exception, for any wires that are completed in any currency other than Canadian dollars. Funds sent by EFT can be in Canadian currency only

Declaration

Please choose which best describes you:(Required)

I am the named beneficiary as set out on the Indigenous Services Canada List

I am NOT the named beneficiary and I am filling out the form for someone else

Please upload a signed notarial copy of the documentation authorizing the signees, on behalf of the beneficiary.(Required)

Max. file size: 256 MB.

I acknowledge that upon receipt of the above, my entitled Per Capita Payment as specified in the ERFN 2023 Trust Agreement. I hereby grant CIBC Trust Corp and English River First Nation a full receipt and complete discharge and indemnity in respect of said Per Capita Payment.

Signature of person signing this form (your full name)(Required)

First Last

Please include a photo of your signature(Required)

Date(Required)

Please Note:

If the person signing this form is not the named beneficiary as set out on the Indigenous Services Canada List, then please attached a signed notarial copy of the documentation authorizing the signees, on behalf of the beneficiary.
If you have any trouble filling out or signing this form, please contact the English River First Nation Registry Department for assistance.
DON’T FORGET to attach a picture or copy of your ID(s) to this form. Forms that are incomplete will not be processed.

Comments

This field is for validation purposes and should be left unchanged.

Settlement Form - (2023 u)

Beneficiary Information

Eligibility

Payment Information

Declaration