Resident of Saskatchewan’s North (RSN) Status

LAST Name: FIRST Name:

Section 1 RSN Self-Declaration Saskatchewan’s North means any of the communities within the Northern Administrative District (NAD). These are listed on the reverse side of this form.

Please check to confirm the following descriptions applies to you: A person who has resided in Saskatchewan’s North for a period of 10 years or one half his or her age, whichever is the lesser. Such a person: • shall not lose status by relocating outside of Saskatchewan’s North for educational purposes; • shall not lose status by relocating outside of Saskatchewan’s North for five years or less; and • shall regain status if he or she has lived outside of Saskatchewan’s North for more than five years but has re-established primary residency in Saskatchewan’s North. Name of the NAD community where you reside or resided:

If you are an RSN who is also First Nations with band membership in northern SK, please identify which First Nation:

Signature: Date:

Section 2 RSN Verification If you identified as RSN in section 1, please provide:

Name of NAD Chief, Mayor, Alderperson or designate:

______

Position ______Community ______Phone number ______

In my capacity as the Chief, Mayor, Alderperson, or designate), I verify that:

(Full legal name) ______is a Resident of Saskatchewan’s North as per the above definition. Signature of verifier ______Date______For any questions please email [email protected] Northern Administrative Communities Northern Administrative First Nations

Air Ronge Black Lake Denesuline Nation Bear Creek Birch Narrows Dene Nation Beauval Buffalo River Dene Nation Black Lake Canoe Lake First Nation Brabant Lake Clearwater River Dene First Nation Buffalo Narrows Cumberland House Cree Nation Buffalo River English River First Nation Camsell Portage Fond du Lac First Nation Canoe Narrows Hatchet Lake First Nation Clearwater River Lac La Ronge Indian Band Cole Bay Montreal Lake Cree Nation Creighton Peter Ballantyne Cree Nation Cumberland House Peter Ballantyne Cree Nation – Southend Denare Beach Deschambeult Lake Descharme Lake Dillon Dore Lake Fond du Lac Garson Lake Grandmothers Bay Green Lake Hall Lake Hatchet Lake Ile a la Crosse Jans Bay Kinoosao La Loche La Plonge La Ronge Michel Village Missinipe Montreal Lake Patuanak Pelican Narrows Pinehouse Sandy Bay Sled Lake Southend St. Georges Hill Stanley Mission Stony Rapids Sturgeon Landing Sucker River Timber Bay Turnor Lake Uranium City Weyakwin Wollaston Lake