ATC OFF-RESERVE COVID-19 SUPPORT FUNDING 2020

ATC OFF-RESERVE COVID-19 SUPPORT FUNDING 2020

APPLICATION FORM
Athabasca Tribal Council Ltd. (ATC) received funding from the “Urban and Off-Reserve Covid-19 Emergency Fund” from Indigenous Services Canada. A condition of the funding is that it is limited to members who do not ordinarily reside on-reserve.

In consultation with the five ATC member nations, Athabasca Chipewyan First Nation and Chipewyan Prairie Déne First Nation will have their ATC Off-Reserve COIVD-19 Support Funding distributed by ATC. Fort McKay First Nation, Fort McMurray 468 First Nation, and Mikisew Cree First Nation will be administering the ATC Off-Reserve COIVD-19 Support Funding for their nations.

More information about the ATC OFF-RESERVE COVID-19 SUPPORT FUNDING or a printable version of this form can be found at www.atcfn.ca/support or you can call ATC at 780-713-2340.
Complete all required fields before submitting your application.

Incomplete forms will not be processed. If you have any questions call ATC at 780-713-2340. Once a complete form is received, processing will take 7-10 business days. Forms submitted before December 14, 2020, will be processed before the Christmas break. Forms submitted after December 14, 2020, will resume processing on January 7, 2021.
All persons listed in this application are members of: *

Athabasca Chipewyan First Nation Chipewyan Prairie Déne First Nation
A "member" is defined as: an individual who is on the Membership List of the Athabasca Chipewyan First Nation or the Chipewyan Prairie First Nation in accordance with each First Nation's Membership Code.
All persons listed in this application are First Nation members who do not ordinarily resident on-reserve and therefore are eligible for ATC Off-Reserve COIVD-19 Support Funding. *

Yes
Please select who this application is for. *

Adult Member On behalf of a Minor Member Household of Members
Adult Member: If you are a Member and are over the age of 18 you are eligible to apply for COVID-19 support funding in the amount of $255.

On behalf of a Minor Member: If you are the parent or guardian of a Minor Member (under the age of 18) you must complete the Acknowledgment of Trustee, Release and Indemnity Agreement in order to accept the Minor Member’s COVID-19 ATC Off-Reserve COIVD-19 Support Funding in the amount of $125.

Household of Members: All family Members who are living at the same address and who wish to receive their COVID-19 support funding in one deposit/cheque should be included in the Household Application. The household includes spouse/common-law partner and/or dependents/children who are Members. NOTE: You must be the guardian of any Minor Members listed in the application and must complete the Acknowledgement or Trustee, Release and Indemnity Agreement for the Minor Members.

Adult Member Application

ATC staff will be confirming membership with Athabasca Chipewyan First Nation or Chipewyan Prairie Déne First Nation membership clerks.
Adult Member *

First Name Middle Name Last Name
Date of Birth *

Year Month Day
Date
Status Card Number *

On behalf of a Minor Member Application

ATC staff will be confirming membership with Athabasca Chipewyan First Nation or Chipewyan Prairie Déne First Nation membership clerks.
Minor Member *

First Name Middle Name Last Name
Date of Birth *

Year Month Day
Date
Minor Member's Status Card Number *
Parent/Guardian Name *

First Name Last Name
Form 1

Guardian’s Acknowledgement of Responsibility

I represent and acknowledge the following:
1. I am the Minor(s)’ guardian and have the power and responsibility to make day-to-day decisions affecting the Minor(s).
2. I request that ATC to deliver to me, to hold as trustee for the Minor(s), money or other property of a total value of $125.00 per Minor that ATC is holding for the Minor(s).
3. When the Minor(s) reaches the age of 18 years I will account to the Minor(s) and transfer the balance of the money or property remaining at that time to the Minor(s).
4. I must use the money or other property only for the Minor(s)’ benefit in accordance with all applicable laws, including but not limited to the Trustee Act of Alberta and the Minors’ Property Act of Alberta as those laws may be replaced or amended from time to time.
5. I cannot borrow or take a benefit from the money or other property.
6. I must keep adequate records of my administration of the money or other property.
7. I will use the money for the administration and maintenance of the Minor(s).
8. I assume full responsibility for the management of the money or other property on behalf of the minor(s), including all responsibilities binding on me as a trustee. I will exercise all the powers and authorities of a trustee in accordance with my legal obligations without personal benefit or expectation of payment and in the best interests of the Minor(s).
9. The trust relationship described in this acknowledgment is permanent and cannot be revoked by me.
Parent/Guardian Signature *

Clear

Acknowledgement of Trustee, Release and Indemnity Agreement
BETWEEN:

ATHABASCA TRIBAL COUNCIL LTD. (the “ATC”)

-and-

First Name* Last Name* (the “Trustee”)

WHEREAS:
1. Upon application, ATC will be making support payments (“ Support Payment ”) to members of the Chipewyan Prairie First Nation and the Athabasca Chipewyan First Nation and some members are minors.
2. The Trustee is a legal guardian of minor member(s), First Name Last Name , First Name Last Name , First Name Last Name , First Name Last Name , First Name Last Name , First Name Last Name , First Name Last Name (the “ Minor(s) ”), and has agreed to act as the trustee for the Minor(s) regarding the Minor(s)’ Support Payment.
IN CONSIDERATION of the payment of the Minor(s)’ Support Payment in the amount of $125.00 per Minor to the Trustee, the Parties agree as follows:
1. “ ATC ” in this Agreement shall be interpreted to include the ATC, its directors, shareholders, officers, employees, administrators, agents, and representatives.
2. The Trustee declares that he or she: is the legal guardian of the Minor(s); accepts the position and obligations of a trustee for the Minor(s) in relation to that Minor(s) Support Payment; and acknowledges that this arrangement is a legal and binding trust relationship for the benefit of the Minor(s).
3. The Trustee has truthfully completed the document and this document forms part of this Agreement:
  1. “Form 1” - Guardian’s Acknowledgement of Responsibility
4. The Trustee understands that the ATC is relying on the accuracy and truthfulness of the information declared by the Trustee in “Form 1.”
5. The Trustee agrees to comply with the laws in effect in relation to acting as a trustee, including but not limited to the Trustee Act of Alberta, Minors’ Property Act , and the Criminal Code of Canada, at all times that he or she holds the Minor(s)’ Support Payment
6. The Trustee agrees that he or she is solely responsible for understanding his or her legal duties and obligations for acting as the Minor(s)’ trustee. The Trustee agrees that any information, documents, or materials provided by the ATC, whether verbal or written and including statements contained in “Form 1” is not legal advice. The Trustee is responsible for getting independent legal advice as needed for the Trustee’s understanding and fulfillment of his or her legal duties and obligations.
7. The Trustee agrees to not commence any legal action or make any demands or claims against the ATC whatsoever in relation to the payment of the Minor(s)’ Support Payment to the Trustee.
8. The Trustee agrees to defend and fully indemnify ATC for all liabilities, demands, damages, costs, including the cost of legal services, and expenses of any kind whatsoever that arise in relation to the payment of the Minor(s)’ Support Payment to the Trustee and/or for the Trustee’s use, management, administration or distribution of the Minor(s)’ Support Payment.
9. The Trustee further agrees to defend and fully indemnify ATC for all liabilities, demands, damages, costs, including the cost of legal services, and expenses of any kind whatsoever should the Minor(s) or a legal representative for the Minor(s) bring any legal action, successful or not, in relation to the payment of the Minor(s)’ Support Payment to the Trustee and/or for the Trustee’s use, management, administration or distribution of the Minor(s)’ Support Payment.
10. Each party has read and understood this Agreement and the attached Form 1.
11. This Agreement may be executed in counterpart and may be signed by facsimile or other electronic means.
12. This Agreement is governed by and interpreted in accordance with the laws of the Province of Alberta. The parties agree that any dispute must be submitted to the courts of Alberta.
13. This Agreement shall be binding upon the parties and their respective heirs, executors, administrators, successors, trustees and assigns.
IN WITNESS WHEREOF the parties have signed this Agreement Date

Trustee Signature

Per:
ATHABASCA TRIBAL COUNCIL LTD.

Deposit & Contact Information

Please include as much contact information as you are able to provide so we can contact you if there is an issue with your application or deposit.
Forms submitted by December 14, 2020 will be processed before the Christmas break. Forms submitted after December 14, 2020 will resume processing on January 7, 2021.
How would you like to receive the funds?

Direct Deposit (3-5 business days) Cheque (3-5 business days plus mailing)
Direct Deposit

Please provide banking information if you prefer direct deposit instead of a cheque.
Bank Information *

Transit Number Institution Number Account Number
Upload VOID cheque or Direct Deposit form from your bank. *

Cancel of
Address *

Street Address

Street Address Line 2

City Province

Postal Code
Phone Number *
E-mail *
Personal Information Protection Act Notification Statement:

I understand that my personal information is being collected under the authority of the Personal Information Protection Act and is subject to the provisions of that Act. My personal information will only be collected, used and disclosed to ATC, the Athabasca Chipewyan First Nation and the Chipewyan Prairie Dene First Nation for the purpose of determining my eligibility for the ATC COVID-19 off-reserve support funding.

If I have questions regarding the collection of my personal information, I can contact:

Contact Name: Elena Gould
Phone: 780-791-6538, ext *222 Email: support@atcfn.ca

I waive all moral rights, claims, and objections arising from the use of my personal information in favour of ATC, its agents, employees, and contractors.
Do you give consent for the Athabasca Tribal Council to collect and store the information I have provided for the purpose of ATC Off-Reserve COIVD-19 Support Funding. *

Yes
Do you give consent to share your first and last name, status number and address with the Chief and Council of your First Nation. Please note that no other private information will be shared. *

Yes
I would like to receive information and news from ATC via the email provided. *

Yes No
Declaration and Acknowledgment

Each applicant over the age of 18 must sign this declaration and acknowledgement.
The information in this application is true and correct to the best of my knowledge *

Yes
I understand that if I have given false or incomplete information, I may be required to repay the support funding to ATC. *

Yes
Signature *

Clear
Should be Empty:

ATC OFF-RESERVE COVID-19 SUPPORT FUNDING 2020

Complete all required fields before submitting your application.

Adult Member Application

On behalf of a Minor Member Application

Household Application

Acknowledgement of Trustee, Release and Indemnity Agreement

Deposit & Contact Information

Direct Deposit

Declaration and Acknowledgment