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
IF
claiming
Level 1 Verbal / Physical Harm
page 6
Part 5
IF
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 recordsclear
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
No
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 HarmVerbal/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.
OR
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
OR
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);
or
loss of
consciousness;
or
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 5AYour 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 5CEvidence 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 5DOther 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 5EMedical / 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
OR
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
R
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
OR
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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