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

1. I am the Individual and / or Adult who is a Registered Member of Alexis Nakota Sioux Nation and entitled to receive the December 17, 2021 per capita distribution grant of ($600.00) Dollars to Individual members:

2. On behalf of the Entitled Individual / Adult, 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 of myself or the Entitled Individual / Adult.

3. I acknowledge and accept full responsibility for this decision made on behalf of the Entitled Individual / Adult 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 Individual / Adult in the manner set out above.

4. 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 Individual / Adult bring any legal action, successful or not, in relation to the payment of this per capita distribution grant in the manner set out above.