<p> INDEMNIFICATION FORM PER CAPITA DISTRIBUTION PAYMENT TO A MEMBER OVER 18 YEARS OF AGE</p><p>I being a member of the Carry The Kettle First Nation acknowledge receipt of the check dated December 14, 2017 in the sum of Five Hundred Dollars ($500.00), which sum represents payment to me for my share of a per capita distribution being made from the Carry The Kettle Capital Trust monies.</p><p>In consideration of the aforementioned payment, I hearby agree to release and forever discharge and indemnify the Carry The Kettle First Nation, its Band Council, servants, agents and employees together with their heirs, executors, administrators, successors and assigns, from any and all manner of action, cause of action, suit, cost, debt, demand or claim whatsoever, whether known or unknown and whether in law, equity or otherwise which I may have by reason of my having received the per capita distribution payment as provided for herein.</p><p>Further, I acknowledge that I shall bear sole responsibility for determining the legal, financial and economic impact, if any, associated with my having received the per capita distribution payment as provided for herein.</p><p>Signed at this day of 2017.</p><p>Name Witness</p><p>Signature Signature</p><p>Registry/Treaty Number</p><p>Method of Payment</p><p>Deposit to personal Bank Account Cheque # .</p><p>Financial Institution .</p><p>Branch . Branch address .</p><p>Transit # . Account # .</p><p>Current Mailing Address .</p><p>.</p><p>.</p><p>Phone Number .</p>