I, the undersigned member of the Alexis Nakota Sioux Nation (referred to as “Alexis”) in the Province of Alberta represent and acknowledge that:

1. I am the parent and / or legal guardian of (The “Entitled Child”) who is a minor and is a Member of Alexis Nakota Sioux Nation and entitled to receive the December 2022 per capita distribution grant of ($700.00) Dollars to Individual members:

2. I have provided proof to Alexis which verifies the age, identity and legal status of me and the Entitled Child.

4. On behalf of the Entitled Child, I accept full responsibility for the consequence of accepting the per capita distribution grant including  effects on income tax, benefits provided under any federal or provincial  statute, or any other matter affecting the financial or other circumstances my myself or the Entitled Child.

5. I acknowledge and accept full responsibility for this decision made on behalf of the  Entitled Child and, in addition to the provisions of section  52.5 of the Indian Act, release the Chief and Council, and Alexis, any  responsibility  of liability what so ever for paying this per capita distribution grant for the Entitled Child in the manner set out above.

6. I further undertake to fully indemnify Alexis, and Alexis Chief and Council, administration, employees and agents for all costs, including legal costs on a solicitor and client basis, and damages of any kind whatsoever in relation to the payment of this per capita distribution  grant. Without limiting the  generally of the foregoing, I further undertake to fully indemnify Alexis and Alexis Chief and Council, administration, and employees and agents for any claims, costs, or damages of any kind whatsoever should the Entitled Child or the Entitled Child’s representative bring any legal action, successful or not, in relation to the payment of this per capita distribution grant in the manner set out above.