Indian Day Schools Individual Claim Form 5 of 15
Part 3: Claimant and Witness Signatures
Claims Administrator (Administrator) and Independent Assessor:
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
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 firstname.lastname@example.org or 1-844-539-3815.
I understand that by signing this Claim Form and submitting it to the Claims
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.
Signature of Claimant (required)
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)
Witness Full Name - First, Last
Witness Address: Street Name and Number; Unit Number
Province/Territory Postal Code Country
Witness Telephone Number Witness Email Address (if available)