Fill - Free fillable INDIAN DAY SCHOOLS CLASS ACTION SETTLEMENT PDF form

INDIAN DAY SCHOOLS

CLASS ACTION SETTLEMENT

Caution:

Filling out this Claim Form may be emotionally

difficult or traumatic for some people.

If you are experiencing emotional distress and want to talk, free

counselling and crisis intervention services are available from the

Hope for Wellness Help Line at 1-855-242-

3310 or online at

www.hopeforwellness.ca.

The toll-free number and website are available

24 hours a day, 7 days a week.

Free legal assistance with the Claims Form is available from

Class Counsel, Gowling WLG at 1-844-539-3815.

Indian Day Schools Individual Claim Form 1 of 15

CLAIM FORM

INDIAN DAY SCHOOLS CLASS ACTION SETTLEMENT

This Settlement is applicable to all students who attended and

suffered abuse or harm at a Federal Indian Day School or Federal

Day School operated by the Government of Canada.

Claim Due By: July 13, 2022

Starting in 1920, Indigenous students were

required to attend

school. Some Indigenous students attended a Federal Indian

Day

School or Federal Day School (“Day School”) that was

funded,

managed and controlled by the

Federal Government of Canada

(“Canada”).

The Federal Indian Day Schools

Class Action Settlement

Agreement (“Settlement

”) provides compensation to any former

day student who attended a Day School and who suffered

abuse or

harm when attending the school.

A list of the eligible Day Schools, along with relevant dates of

their

management and

control by Canada, is available at

www.indiandayschools.com (Schedule K of the Settlement).

Class Counsel and available legal advice: legal advice

with

respect to eligibility and harms experienced is available at no cost

to you from Class Counsel, Gowling WLG,

by contacting

dayschools@gowlingwlg.com or 1-844-539-3815.

Indian Day Schools Individual Claim Form 2 of 15

CLAIM FORM

The Settlement provides for compensation to former Day School

students who both:

a) attended

Federal Indian Day School(s) and Federal Day

School(s) funded, managed and controlled by Canada

AND

b) suffered abuse or harm from

teaching staff, officials,

students and other third parties at the school.

To be eligible for compensation, students must not have already

received a settlement from Canada for the same or related

incident(s) at a Federal Indian Day School or Federal Day School

as identified in this Claim Form.

Former Day School students are collectively identified as Survivor

Class Members.

If you believe you are a Member of the Class, please complete

this Claim Form to the best of your ability.

Part 1

Your name, contact details and date of birth page 3

Part 2

Day School(s) and the years you attended page 4

Part 3

Consent and Signature Page page 5

Part 4

claiming

Level 1 Verbal / Physical Harm

page 6

Part 5

claiming

Level 2, 3, 4, or 5 Sexual / Physical Harm

pages 7-11

Part 6

Complete only if you are missing required document(s)*

page 12

Part 7

Complete only if you are a legal representative of a Claimant

page 13

Before sending, please review the Retention Policy

and Submission Process on pages 14 and 15

Please make sure to keep a copy of your Claim Form

and any attached documents for your personal records.

* Do not send original photographs, identification or records – clear

photocopies will be accepted.

Indian Day Schools Individual Claim Form 3 of 15

Part 1: Information of Former Day School Student (Claimant)

Claimant Name and Last Name (required)

First Name:

Middle Name: (if applicable)

Last Name:

Other name(s) (if applicable) Examples: name while attending the school, maiden name,

adopted name, nickname, or E-Disc/W-Disc name/number (Inuit)

Claimant’s Date of Birth (required) If Claimant has died, Date of Death

DD_____MM_____YY_____ DD_____MM_____YY_____

Indian Status Card number or

Beneficiary number

Social Insurance Number

_______________________

__ __ __ - __ __ __ - __ __ __

Claimant Contact Details (required)

Street Name and Number

Unit Number (if applicable)

City/Town/Community

Province/Territory Postal Code Country

Home Telephone Number Mobile Telephone Number

Email Address (if available)

Claimant’s current Home Community or Communities (if applicable)

Examples: Name of First Nation, Town, Hamlet, or Settlement

Indian Day Schools Individual Claim Form 4 of 15

Part 2: Where and When did you attend the School(s)?

To be eligible for compensation, you must have attended an eligible

Day

School during the period

when it was funded, managed and controlled by

Canada (Class Period).

Day Schools covered by the Day School Settlement, along with their opening

and closing dates, are listed at www.indiandayschools.com (

Schedule K of

the Settlement).

Identify the Day School you attended and years

attended. If you attended more than one (1) school, please list

each

separately below.

Name of Day School #1

(required)

Reserve, Location or Community

Province or Territory

First Year of Attendance

Year attended (yyyy) or Age when attended

1 9 __ __ ___ ___

Last Year of Attendance

Year attended (yyyy) or Age when attended

1 9 __ __ ___ ___

Add additional details below only if

you attended more than one Day School (if applicable)

Name of Day School #2

Reserve, Location or Community

Province or Territory

First Year of Attendance

Year attended (yyyy) or Age when attended

1 9 __ __ ___ ___

Last Year of Attendance

Year attended (yyyy) or Age when attended

1 9 __ __ ___ ___

Indian Day Schools Individual Claim Form 5 of 15

Part 3: Claimant and Witness Signatures

Claims Administrator (Administrator) and Independent Assessor:

I recognize that the

Administrator and Independent Assessor do not:

 represent the Day Schools or Canada;

 act as an agent or legal counsel for any party, and do not offer legal advice; and,

 have any duty to identify or protect legal rights of any party, or to raise an issue not raised by

any party.

Privacy: I understand that it may be necessary:

 for the Administrator to disclose information provided in this Claim for verification to: Canada;

the Independent Assessor; the Exceptions Committee (if applicable); and Class Counsel; and

 for Canada to disclose information in its possession to: the Administrator; the Independent

Assessor; the Exceptions Committee (if applicable); and Class Counsel.

Information in Claim Form

: I confirm that all of the information provided in this Claim Form is

true to the best of my knowledge. Where someone helped me complete this Claim Form, that

person has read to me everything they wrote and included with this Claim Form.

Class Counsel and legal advice: I understand that free legal advice is available from Gowling

WLG by contacting dayschools@gowlingwlg.com or 1-844-539-3815.

Consent:

I understand that by signing this Claim Form and submitting it to the Claims

Administrato

r, I am consenting to the above, and to the disclosure of my personal

information to be used and disclosed in accordance with the Settlement.

Other/Prior Settlement (required):

Please check YES or NO to this question: have you already received money from

Canada for the same abuse/harm at a Federal Indian Day School(s) or Federal Day

School(s) as described in this Claim Form?

This does not include Indian

Residential Schools payments. If you are unsure, contact Class Counsel.

Yes



Signature of Claimant (required)

Date

DD_____MM_____YY_____

The Witness must only see the Claimant sign this page. They are not

required to read the Claim nor to verify the accuracy of the events.

Signature of Witness (required)

Date

DD_____MM_____YY_____

Witness Full Name - First, Last

Witness Address: Street Name and Number; Unit Number

City/Town/Community

Province/Territory Postal Code Country

Witness Telephone Number Witness Email Address (if available)

Indian Day Schools Individual Claim Form 6 of 15

Part 4: Claim for Level 1 Harm – Verbal/Physical Abuse

If the abuse/harm described in Level 1 ($10,000) represents the

most serious

abuse/harm(s) that

you experienced while attending the Day School, please complete

this section by placing a mark in the box below.

Abuse/harm may have been from teachers, officials, students, and/or other third parties.

If the abuse/harm in Level 1 does not represent the most serious harm(s)/

abuse you

experienced

, please skip this section and complete a higher Claim Level (Levels 2 to 5)

in Part 5, as appropriate.

LEVEL 1 – Description of Verbal / Physical Abuse or Harm

Verbal Abuse or Harm, including:

 Mocking, or denigration (e.g. belittling or abusive language), or humiliation (e.g.

shaming) by reason of Indigenous identity or culture; or

 Threats of violence or intimidating statements; or

 Sexual comments or provocations.

Physical Abuse or Harm, including:

 Unreasonable or disproportionate acts of discipline or punishment.

LEVEL 1 – Selection

If the description of abuse/harm above represents the most serious abuse/harm

that you experienced, please select Level 1 by placing a mark in this box.

NEXT STEPS

If you selected Level 1 above, no further description is required.

Please submit your claim form along with a photocopy of government issued piece of identification (e.g.

Indian Status Card, Driver’s license, Social Insurance Card, etc.).

PLEASE PROCEED TO PARTS 6 and 7, if applicable, on pages 12-13,

and review pages 14 and 15

Indian Day Schools Individual Claim Form 7 of 15

Part 5: Claims Process for Levels 2, 3, 4, or 5

STEP 1: Identify the ABUSE or HARM you suffered from

teachers, officials,

students, and/or other third parties.

Abuse / Harm LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

Sexual

Abuse/Harm

At least one sexual incident of any one of:

Repeated sexual

incidents of any

one of:

 touching of

genitals or

private parts;

 adult(s)

exposing

themselves;

 fondling/kissing;

 nude photos

taken

 masturbation;

 oral

intercourse;

 attempted

penetration

 penetration;

 penetration

with an object

 masturbation;

 oral intercourse;

 penetration;

 penetration with

an object

Physical

Abuse

Harm

At least one

incident of

physical abuse /

assault, causing:

At least one

incident of

physical abuse /

assault,

causing:

Repeated (at

least two)

incidents

of physical

abuse / assault,

causing:

During an incident

of any one sexual

abuse / assault

described above at

least one incident

of physical abuse /

assault, causing:

CAUSING:

serious but

temporary harm:

 injury requiring

bed rest or

infirmary stay

(e.g., in school

medical room or

hospital);

 loss of

consciousness;

 broken bone(s)

permanent or long-term harm:

 injury; or

 impairment (e.g., physical or mental); or

 disfigurement

STEP 2: Select your Claim Level, by placing a mark in one box below, for the Level

of abuse / harm you suffered as identified above.

Level 4

$150,000

Level 5

$200,000

Level 2

$50,000

Level 3

$10

0,000

Place a MARK

in ONE box:

Indian Day Schools Individual Claim Form 8 of 15

Part 5: Claims Process for Levels 2, 3, 4, or 5

STEP 3: Provide SUPPORT for the Level selected by completing sections as listed

below.

SUPPORT LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

Your

Identification

Required*

Provide a photocopy of government issued piece of identification

(e.g. Indian Status Card, Driver’s license, Social Insurance Card, etc.)

Your Written

Narrative of

events

Must complete 5A

List of position/

person(s) who

inflicted or

caused the

abuse/harm

Only if available

Complete 5B

Must complete 5B

Evidence of

School

attendance

Required*

Complete 5C and attach documents

Family / Friend

narratives or

other records

Only if available

Complete 5D and attach

documents

Required*

Complete 5D and attach

documents

Medical,

Dental,

Nursing or

Therapy

Records

Only if available

Complete 5E and attach

documents

Required*

Complete 5E and attach

documents

* If you do not have the documents marked above as Required*,

you must complete a Sworn Declaration; see Part 6

Indian Day Schools Individual Claim Form 9 of 15

Part 5: Claim for Levels 2, 3, 4, 5 only

Part 5A – Your Written Narrative (required)

Please provide in writing, a description of the specific event(s) that led to the abuse/harm

that you experienced when attending the Day School, related to your Level 2, 3, 4 or 5

claim above.

If you require additional space, please attach pages to your Claim

Form and reference this section.

Please include the following:

 Description of events including names, places and dates (to the best of your ability)

 If applicable: describe medical attention required / sought / received at the time

and/or currently as directly related to the abuse/harm suffered at the Day School

Indian Day Schools Individual Claim Form 10 of 15

Part 5: Claim for Levels 2, 3, 4, 5 only

Part 5B – List of position / person(s) who inflicted abuse/harm

List of position /

person(s) who caused

abuse/harm

LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

Only if available Must Complete

Please provide names / descriptions and/or positions of person(s) (e.g.

teaching staff,

officials, students and other third parties) who caused abuse/harm

to you while you

attended the Day School. If you need more

space, please attach pages to your Claim

Form and reference this section (Part 5B).

Name / Description and / or

Position

Part 5C – Evidence of Attendance

Attach school records

LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

Required*

* If you do not have the required documents for Level 2, 3, 4 and 5,

complete Part 6: Sworn Declaration *

Please list below and attach to this Claim Form,

evidence of your school attendance,

including copies of any of your school records issued by the Day School(s) you attended,

during any of the years of your attendance. Examples may include copies of:

 Report Cards

 Enrolment Forms

 Class Photographs

 Letter(s) from teacher

or principal



Other Records, like

yearbook or school

articles

List the record(s) attached to this Claim Form:

Indian Day Schools Individual Claim Form 11 of 15

Part 5: Claim for Levels 2, 3, 4, 5 only

Part 5D – Other narratives and records

Attach Family / Friend

narratives or other

records

LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

Only if available

Required*

* If you do not have the required documents for Levels 4 or 5,

complete Part 6: Sworn Declaration *

Please list below and attach

to this Claim Form, copies of other written narratives from

friends/family and/or other records that support the events and incident(s) that led to the

abuse(s)/harm(s) you experienced while attending the Day School(s). Examples may include:



Family narratives

 Friend narratives



Photographs

 Diaries



Other

List the narratives / records attached to this Claim Form:

Part 5E – Medical / Dental / Nursing / Therapy Records

Attach Medical, Dental,

Nursing and / or

Therapy Records

LEVEL 2 LEVEL 3 LEVEL 4 LEVEL 5

Only if available

Required*

* If you do not have the required documents for Levels 4 or 5,

complete Part 6: Sworn Declaration *

Please list below and attach to this form any copies of medical, dental, nursing and/or therapy

records that support your claim. This may include current or past health records that

document the injury you suffered and any lasting effect to this day. List the Medical records

attached to this Claim Form:

Indian Day Schools Individual Claim Form 12 of 15

Part 6: Sworn Declaration

Sworn Declaration if any missing required document(s) (if applicable)

You must complete the following Sworn Declaration only if

you are missing one or more of the

required documents:

• for Level 2, 3, 4 or 5 documents(see page 8), and/or

• a photocopy of government issued piece of identification

A Sworn Declaration is a statement signed by the claimant and any one of

the following

Guarantors, with Titles:

 Notary Public or Commissioner of Oaths including Northern Villages’ Secretary Treasurer

Elected Official or Community leader (e.g. Chief, Councilor, Inuit Community Leader)

 Other Professional (e.g. Lawyer, Doctor/Physician, Accountant (CPA), Police Officer)

Sworn Declaration by Claimant:

I declare that the information I have provided is true to the best of my knowledge

Claimant Full Name - First, Last

Signature of Claimant

Date

DD_____MM_____YY_____

Above declaration must be witnessed by a Guarantor.

The Guarantor only needs to see the Claimant sign this page. As Guarantor, you are not

required to read the Form or verify the accuracy of the events described in this Form.

Guarantor must complete all fields below.

Guarantor Full Name - First, Last

Guarantor Title Position Organization

Guarantor Address: Street Name and Number; Unit Number (if applicable)

City/Town/Community

Province/Territory Postal Code Country

Telephone Number Email Address (if available)

Signature of Guarantor

Date

DD_____MM_____YY_____

Indian Day Schools Individual Claim Form 13 of 15

Part 7: Are you applying as a Representative of a Claimant?

If applicable, a Personal Representative must be either:

Appointed by a Court to manage or

make reasonable judgments or

decisions in respect of the affairs of

the person under disability

The Estate Executor or Administrator, appointed

by a Court or the Crown-Indigenous Relations and

Northern Affairs Canada (INAC/CIRNAC), on

behalf of a Claimant who is deceased on or after

July 31, 2007

To become appointed as a Personal Representative for a deceased Claimant that lived on

reserve, please contact INAC/CIRNAC at: 1-800-567-9604. All other appointments are managed

by the local Province or Territory.

If you are applying as a Representative, on behalf of a Claimant,

check this box:

Yes 

If you selected Yes, Representative to provide details below

Representative Full Name - First, Last

Representative Address: Street Name and Number; Unit Number

City/Town/Community

Province/Territory Postal Code Country

Telephone Number Email Address (if available)

Relationship to the Claimant:

Documentation Required

Powers of Attorney Executors / Administrators

• Court Order; or

• Documentation

that shows you

have Power of Attorney over the

Claimant’s finances.

• Death Certificate and a Will;

• Revenue Québec Estate Form; or

• Order or Grant of Administration from a Court; or

• Letters of Administration from INAC/CIRNAC

List the attached documentation you have included:

Indian Day Schools Individual Claim Form 14 of 15

Retention of Claim Form and Documents

You can choose to have your Claim Form and supporting documents

attached to the form:

Please check one:

A) Securely Destroyed; Or

B) Returned to you; Or

C) Delivered to the Legacy Fund*

Destroy

eturn

Legacy*

* Under the Settlement Agreement, the McLean Day Schools Settlement Corporation will be

established to promote Legacy Projects for commemoration, wellness/healing, and the

restoration and preservation of Indigenous languages and culture. The Corporation will be

managed by Directors (to be appointed by the Parties to the Agreement), with input from an

Advisory Committee (representative of Indigenous survivors and their families). For more

information, refer to the Agreement and visit [www.indiandayschools.com].

THIS SPACE IS INTENTIONALLY LEFT BLANK

Indian Day Schools Individual Claim Form 15 of 15

Submission Process

Claim Due By: July 13, 2022

Before sending, please make sure your Claim Form package includes the following:



Claimant name and contact information in Part 1



Attached a photocopy of government issued piece of identification (e.g. Indian

Status Card, Driver’s license, Social Insurance Card, etc.), or if unavailable, had a

guarantor sign the claim form (page 12) in Part 6



Names and details for School(s) attended by the Claimant in Part 2



Signatures of Claimant and Witness in Part 3



Selected ONE claim Level 1-5:



 Level 1 –

Verbal/Physical

Abuse/Harm:

 ticked the box on page 6 in Part 4



 Levels 2, 3, 4, or 5 –

Sexual/Physical

Abuse/Harm:

 ticked one box on page 7 and

 completed Part 5 including written narrative

(page 9), and

 attached documents or had a guarantor sign

the claim form in Part 6 (page 12)



For Representatives, completed Part 7 only if you are a representative submitting

this claim on behalf of Claimant

Please make a copy of your Claim Form and any attached documents

for your personal records.

Original photographs or records are not required.

For questions or to report an address change, contact 1-888-221-2898

PLEASE SEND YOUR CLAIM PACKAGE:

To: Indian Day Schools Class Action Claims Administrator, c/o Deloitte

By Mail: PO Box 1775, Toronto, ON, Canada, M5C 0A2 , or

By Fax: 416-366-1102 , or

By Email: indiandayschools@deloitte.ca

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INDIAN DAY SCHOOLS CLASS ACTION SETTLEMENT

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