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Claim Form for IndividualsThe First Nations Drinking Water Settlement will compensate members of First Nations that experienced longterm drinking water advisories while living on an Impacted First Nation.*You might not need to fill out this form. Please check www.firstnationsdrinkingwater.ca first, to see if yourFirst Nation has filed a claim on behalf of its members. If it has, then please call the Administrator and they’llhelp you check if you’re already on our list. If you are, then you only need to fill out this form if you’re claimingfor Specified Injuries.This is the form to claim compensation for yourself. If you want to make a claim for someone else (forexample a minor child, a person under a disability, or a person who has passed away) then please fill out the‘Claim Form on Behalf of Another Person’ found at www.firstnationsdrinkingwater.caTo qualify for compensation, you must Be a member of a First Nation, have been alive on November 20, 2017, and If born before November 20, 1995If born on or after November 20, 1995ordinarily resided / lived on anImpacted First Nation during a longterm drinking water advisory thatlasted continuously for a year orlonger, anytime between November20, 2013 and June 20, 2021ordinarily resided / lived on anImpacted First Nation during a longterm drinking water advisory thatlasted continuously for a year orlonger, anytime between November20, 1995 and June 20, 2021*For a list of Impacted First Nations and dates of long-term advisories, please see below at pages 6 to 12. Also, please note that Tsuu T’ina, SuckerCreek, Ermineskin Cree, the Blood Tribe, and the Okanagan Indian Band are bringing their claims in a different way, so their members aren’t eligiblefor compensation under this settlementFilling out this form might be confusing, emotionally difficult, or even traumatic.But you are not alone. There are three teams of people available to help.The Hope for Wellness Team offers comfortand emotional support.The Administrator handles claim applicationsand payments.They can help you if you are experiencingemotional distress.They can help you with the claims process,including with filling in this Claim Form.You can reach them toll-free on our WellnessHelp Line at 1-855-242-3310 or online atwww.hopeforwellness.caStart with these folks if you have a questionand don’t know who to ask.You can reach them toll-free on ourAdministrator Help Line at 1-833-252-4220The Class Counsel Team are your lawyers.They work for you, calls are confidential, andthere’s no charge to talk with them.They can help you with claims for SpecifiedInjuries Compensation or legal questionsabout the class action settlement.You can reach them toll-free on ourClass Counsel Help Line at 1-833-265-7589There is a deadline! If your First Nation has not already submitteda form for you, then you must submit one for yourself by March 7, 2023First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 1 of 20

This form has three parts you must fill out, and two parts that are optional.The three parts you must fill out are Part 1:Your Name and Key DetailsThis is where you share key details like your name andbirthday, your address and contact numbers, payment info,and a copy of your ID. This allows us to create a file for you.Part 2:Where You LivedHere, you’ll tell us about the place (or places) where youlived. We use this information to figure out how long yousuffered under long-term drinking water advisories.Part 3:AuthorizationThis is where you agree to the terms and conditions, promisethe information you gave us is correct, and give uspermission to review and decide your application.The next two parts are optional. You do not have to fill them out unless you want to make aclaim for additional compensation for Specified Injuries, or you do not have anyidentification.Part 4:SpecifiedInjuriesThis section is where you can claim for additionalcompensation if you suffered serious, long-lasting injuries thatwere caused either by using water in accordance with the longterm drinking water advisory, or because you didn’t haveaccess to clean safe water because of a long-term drinkingwater advisory. Please note that you must have been using thetreated or tap water. Using untreated water from surfacewater sources such as lakes, pond, or rivers is not covered.Part 5:Sworn/AffirmedDeclarationThis is where you sign your name, promise the informationyou’ve given us is correct, and give us permission to review anddecide your application for Specified Injuries compensation.Because the Specified Injuries compensation is additional towhat everyone who suffered under a long-term drinking wateradvisory will get, an approved guarantor, such as a communityleader, also needs to sign this section as your witness. This Partis also required if you do not have any identification.Tips and PointersIf you’re unsure about anything, the FrequentlyAsked Questions (FAQ) page is a great place tostart. It is available online atwww.firstnationsdrinkingwater.caThere’s a checklist at the end of this form tohelp you make sure you’ve filled out all the rightsections. Instructions on how to submit thisform are at page 14.If you’re still unsure after looking at the FAQ page,please call the Administrator. Their contact info ison page 1.Once the Administrator has sent a decision toyou about your claim, no more changes to yourform can be made.You should only submit this form once, so pleasemake sure you gather all the info you need first.After you’ve submitted, please call theAdministrator if you need to make a change or haveany questions or concerns.This process is governed by the SettlementAgreement and related documents, which are atwww.firstnationsdrinkingwater.caIf you want to make a Specified Injuries claim(Part 4) then you must fill out this form!First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 2 of 20

PART 1: YOUR NAME AND KEY DETAILSPlease fill in all you can here, so we can process your claim. What you writedown should match what is on your government-issued ID. If a box doesn’t applyto you, please just leave it blank.First Name (required)Middle Name(s) (if applicable)Last Name (required)Other Name(s) known by (if applicable)Date of Birth (required)Day Month YearPlease attach a copy of a government-issued IDto this Claim Form (required)I have attached a copy of my government-issued IDWe understand that you might not have all this information, but please fill in allyou can. Note that you must provide the Province and the name of your Band,and either your Indian Status Card Number and/or your Band RegistrationNumberSocial Insurance Number (if available)- -Indian Status Card NumberYour Band Registration NumberName of the Band you are a Member ofProvince Where Your Band is LocatedWhat we need here is your current mailing address or an address where youcan be reached. We also ask for your phone number and email, but if you don’thave those that’s fine, please just leave those boxes blank.Street Name and NumberUnit Number (if applicable)City / Town / CommunityPO Box (if applicable)Province/TerritoryPostal CodeCountryHome TelephoneMobile Telephone (if applicable)Email address (if applicable)If this address is in a First Nation, please indicatethe name of the nationC/O Name (if applicable)First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 3 of 20

Payment InformationPayments will be assessed and issued to eligible claimants after the end of theclaims periodThe claims period ends on March 7, 2023, so payments will be in mid-2023 orlaterCompensation will depend on the total amount of funding available, and numberof eligible claims receivedIf your claim is approved, we can pay you by chequeor by direct deposit. Which would you prefer?Please mail me acheque at the addressI provided aboveI have attached a completeddirect deposit form or voidcheque and would like youto pay me by direct depositTips and Pointers for Direct DepositsIf you’d like a direct deposit, you mustattach a void cheque or direct depositform to this claim form, so we knowwhere to send the money.The bank account needs to be in yourname. We can’t send money to someoneelse’s account. If your account changes,please contact the Administrator.We can only deposit to Canadian bankaccounts.If you move after you send us this ClaimForm, please make sure you contact theAdministrator at 1-833-252-4220 andgive us your new address!Please make sure the information yougive us is correct. Once the money isdeposited, we can’t get it back or makereplacement payments. For example, ifyou provide a family member's bankinginformation instead of your own, wecan’t get that money back for you.If the void cheque or direct deposit formare invalid, we will mail your chequeinstead.First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 4 of 20

PART 2: WHERE YOU LIVEDIn this section, you’ll tell us about what reserve(or reserves) you lived on, and when. We will usethat information to figure out how muchcompensation you are eligible for.There’s a long table below, listing all the FirstNations that had known long-term drinking wateradvisories in the timeframes covered by thesettlement. As a reminder, a ‘long-term drinkingwater advisory’ means one that lasted for a yearor longer.Beside the name of each First Nation, there are dateboxes. Please fill in the date boxes next to the FirstNation where you lived, starting with the month andyear you began living there, and ending with the monthand year you stopped living there (if applicable).If you were born before November 20, 1995, then pleaseshare with us where you lived fromNovember 20, 2013 to June 20, 2021.If you were born on or after November 20, 1995, thenplease share with us where you lived fromNovember 20, 1995 to June 20, 2021.Tips and Pointers for Part 2You only need to share the times and locations that you were living on any of the FirstNations listed below. You don’t need to share information about other times and locations.If you were under 18 when you lived on reserve and moved away from your community toattend school, that time should be treated as time spent living on reserve and included in thetable below.If you lived in more than one First Nation on the list below, that’s fine. Please complete thedate information for all the listed First Nations that you lived in.If you have questions about why we’re only asking for certain timeframes based on when youwere born, please see the ‘Limitations Periods’ section of the online FAQ page. You can find itat www.firstnationsdrinkingwater.caIf you think your First Nation had a drinking water advisory that lasted a year or more, butyou can’t find it on the list below, please call the Administrator at 1-833-252-4220, or includethe information in the ‘Other First Nation(s)’ section at the bottom.First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 5 of 20

AlbertaFirst Nation /Band NumberFirst NationDates of Water AdvisoryAlexis Nakota Sioux Nation437Anishinabe Tallcree First Nation446Beaver First Nation445Aug 21, 2007 - Mar 31, 2016Dec 10, 2003 - Feb 02, 2005May 22, 2008 – Mar 18,2011Aug 28, 2009 - Jul 27, 2015Cold Lake First Nation464Sep 17, 2010 - Dec 15, 2011Dene Tha' First Nation448Driftpile First Nation450Enoch Cree Nation440Frog Lake First Nation465Kapawe'no First NationKehewin Cree NationJan 17, 2003 - Nov 10, 2006Apr 29,2008 – Mar 19, 2015Jul 04, 2017 – Aug 27, 2018Sep 22, 2011 - Sep 13, 2013I lived on thisImpacted First NationFROM: Month, YearI lived on thisImpacted First NationUNTIL: Month, YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , Year452May 25, 2015 - Jun 09, 2018Jul 14, 2005 - May 11, 2007Sep 07, 2007 – Apr 23, 2012Sep 06, 2012 – Jun 27, 2014Feb 25, 2016 – Nov 16, 2017Sep 29, 2009 - Apr 16, 2018Month , YearMonth , Year466Apr 23, 2011 - Sep 10, 2020Month , YearMonth , YearLittle Red River Cree Nation447Jul 14, 2005 - May 04, 2007Month , YearMonth , YearMikisew Cree First Nation461Feb 01, 2013 – May 28, 2015Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearAug 30, 2007 - Feb 17, 2009Oct 24, 2011 – Jan 13, 2014Aug 24, 2009 - Dec 01, 2010Oct 01, 2004 - May 12, 2006Oct 30, 2009 – Jun 2, 2014O'Chiese First Nation431Paul First Nation441Saddle Lake First Nation462Samson Cree First Nation444Jul 15, 2010 - Nov 27, 2017Month , YearMonth , YearSiksika Nation430Month , YearMonth , YearStoney Nakoda First Nation471Month , YearMonth , YearSturgeon Lake Cree Nation455Month , YearMonth , YearSunchild First Nation434Month , YearMonth , YearWhitefish Lake First Nation #459459Month , YearMonth , YearWoodland Cree First Nation474Sep 12, 2011 – Oct 22, 2013Nov 27, 2001 - Aug 02, 2005Oct 20, 2006 – Mar 21, 2014Jan 29, 2014 - Jun 15, 2015Oct 19, 2015 – Nov 28, 2016Jul 21, 2005 - Jul 27, 2007Aug 21, 2009 – Aug 22, 2014Oct 25, 2002 - Dec 09, 2005May 24, 2011 – Oct 17, 2018Aug 27, 2010 - Sep 07, 2011Month , YearMonth , YearI lived on thisImpacted First NationFROM: Month, YearI lived on thisImpacted First NationUNTIL: Month, YearJun 21, 2010 - Jun 20, 2021Sep 20, 2013 - Jun 20, 2021Sep 02, 2002 - Oct 27, 2005Dec 07, 2012 – Nov 24, 2015Apr 24, 2009 - Jun 20, 2021Oct 08, 2004 - Apr 23, 2009Jan 01, 2001 - Jun 14, 2002Oct 06, 2017 – Jun 20, 2021Jul 01, 2001 - Jun 10, 2004Feb 09, 2006 – Jun 20, 2021Feb 21, 2014 - Jun 20, 2021Apr 01, 2001 - Feb 02, 2006Jan 08, 2007 – Jun 20, 2021Oct 07, 2011 - Feb 01, 2013Nov 06, 2013 – Jul 31, 2015Jul 19, 2005 - Jun 20, 2021Jan 01, 2001 - Jun 10, 2004May 07, 2009 – Aug 02, 2013Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearAug 01, 2001 - Jun 20, 2021Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearBritish ColumbiaFirst Nation /Band NumberFirst NationʔAkisq'nuk First Nationʔaq̓ am (also known as St. Mary’s Indian Band)604602ʔEsdilagh First Nation709Adams Lake Indian Band684Ashcroft First Nation685Bonaparte First Nation (formerly Bonaparte Indian Band)686Boothroyd Indian Band700Canim Lake Band713Cheam First Nation584Coldwater Indian Band693Cook's Ferry Indian Band694Cowichan Tribes642Douglas First Nation (also known as Xa’xtsa Nation or DouglasIndian Band)Dzawada'enuxw First NationEhattesaht First Nation561636634Dates of Water AdvisoryJan 01, 2000 - Apr 01, 2003Sep 02, 2015 – Sep 13, 2016May 15, 2019 - May 15, 2020Jun 23, 2006 - Aug 15, 2008First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 6 of 20

British ColumbiaFirst Nation /Band NumberFirst NationI lived on thisImpacted First NationFROM: Month, YearI lived on thisImpacted First NationUNTIL: Month, YearOct 21, 2004 - Mar 22, 2016Mar 15, 2002 - Jun 16, 2004Apr 01, 2001 - Jun 04, 2003Sep 15, 2004 – Oct 03, 2005Oct 01, 2001 - Apr 01, 2003Jul 30, 2004 – Nov 18, 2005Aug 24, 2015 – Jun 20, 2021Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearDates of Water AdvisoryEsk'etemcFort Nelson First NationHalfway River First NationHupačasath First Nation711543546664Huu-ay-aht First Nation663Kanaka Bar Indian Band (T'eqt'aqtn'mux)Kitasoo (Xai’xais) NationKitsumkalum BandKwadacha Nation704Nov 01, 2001 - Jun 10, 2004Month , YearMonth , Year540681610Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearKwakiutl First Nation626Month , YearMonth , YearKwikwasut'inuxw Haxwa’mis First NationLake Babine Nation625607Month , YearMonth , YearMonth , YearMonth , YearLeq'á:mel First Nation (formerly Lakahahmen First Nation)579Month , YearMonth , YearLhoosk'uz Dené NationLhtako Dené NationLil’Wat NationLittle Shuswap Lake Band721715557689Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearLower Nicola Indian Band695Month , YearMonth , YearLower Similkameen Indian Band (Smelqmix)Lytton First NationMcLeod Lake Indian BandNadleh Whut’en First Nation598705618612Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearNazko First Nation720Month , YearMonth , YearNeskonlith First NationNicomen Indian Band690696Month , YearMonth , YearMonth , YearMonth , YearNooaitch Indian Band699Month , YearMonth , YearN'QuatquaOsoyoos Indian BandPacheedaht First Nation (formerly Pacheena orPacheenaht)Penticton Indian BandPeters First NationQualicum First NationSaik’uz First NationSaulteau First NationsSekw’el’was (also known as Cayoose Creek Band)Semiahmoo First Nation556596Jan 16, 2002 - May 13, 2005Sep 10, 2007 - Jun 20, 2021Jun 30, 2009 - Jun 29, 2015Sep 01, 2001 - Apr 01, 2003May 15, 2019 - Jun 20, 2021Aug 01, 2000 - Jan 07, 2008Sep 30, 1999 - Jun 17, 2015Oct 20, 2006 - Jan 17, 2017Jul 21, 2017 – Jun 20, 2021Nov 26, 2007 - Aug 07, 2015Jan 01, 1999 - Jun 12, 2015Jul 12, 2019 – Jun 20, 2021May 08, 2009 - Jun 20, 2021Jan 13, 2006 - Mar 19, 2008Apr 27, 2009 – Jul 22, 2010May 22, 2012 – Jun 20, 2021Nov 28, 2005 - Jun 20, 2021Jan 01, 2000 - Jun 20, 2021Nov 16, 2006 - Dec 01, 2008Jun 01, 2004 - Jun 17, 2015Jan 01, 1999 – Dec 03, 2015Apr 21, 2020 – Jun 20, 2021Mar 30, 2013 - Jun 20, 2021Dec 27, 2006 - Jan 04, 2008Jun 11, 2010 - Feb 26, 2015Mar 16, 2017 – Jun 20, 2021Apr 24, 2008 - Jun 20, 2021Aug 21, 2007 - Jun 20, 2021Month , YearMonth , YearMonth , YearMonth , Year658Aug 08, 2008 - Apr 15, 2010Month , YearMonth , Year597586651615542591Jun 03, 2008 - Jun 20, 2021Aug 22, 2019 – Jun 20, 2021Jun 15, 2007 - Aug 15, 2008Jan 07, 2020 – Jun 20, 2021Feb 17, 2005 - Jun 20, 2021Feb 25, 2019 - Jun 20, 2021Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , Year569Oct 24, 2003 - Mar 16, 2005Oct 13, 2005 – Jun 20, 2021Month , YearMonth , YearShíshálh Nation (also known as Sechelt First Nation)551Month , YearMonth , YearShuswap First Nation605Month , YearMonth , YearSimpcw First Nation691Month , YearMonth , YearSiska First Nation706Month , YearMonth , YearSkeetchestn Indian BandSkidegate Band CouncilSkuppah Indian BandSkwxwú7mesh Úxwumixw (Squamish Nation)Snuneymuxw First NationSoowahlie First Nation (also known as Soowahile Band)Splatsin First Nation687670707555648572600Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearSpuzzum First Nation708Apr 14, 1997 - Mar 16, 2005Jan 01, 2001 – Nov 08, 2006Sep 25, 2009 – Jun 20, 2021Jun 16, 2008 - Jun 20, 2021Aug 21, 2006 - May 07, 2010May 23, 2012 - Apr 24, 2017May 13, 2010 - Jun 20, 2021Jun 16, 2011 - Jun 20, 2021Dec 20, 2002 - May 07, 2004Oct 07, 2011 - Jan 28, 2013Jul 30, 2007 - Jun 01, 2017Nov 08, 2005 - Jun 20, 2021Jul 10, 2014 - Feb 15, 2017May 01, 2001 - May 02, 2002Month , YearMonth , YearSq’ewá:lxw (also known as Skawahlook First Nation)582Jul 10, 2012 - Jun 20, 2021Month , YearMonth , YearJun 30, 2003 – Aug 05, 2008First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 7 of 20

British ColumbiaFirst Nation /Band NumberFirst NationSq’éwlets First Nation (also known as Scowlitz First Nation)568Stellat'en First NationSts'ailes Nation (also known as Chehalis Indian Band)Stswecem'C Xgat'tem First Nation (formerly Canoe Creek)T’l’esqox First Nation (Toosey First Nation)T’la’tlasikwala First NationT'It'q'et First Nation (formerly known as Lillooet Indian Band)Takla Lake First Nation (formerly known as Takla LandBand)TsartlipTk'emlúps te Secwe̓pemc (formerly Kamloops Indian Band)Tl'azt'en First NationTl'etinqox-t'In GovernmentTobacco Plains Indian Band (Yaq̓ it ʔa·knuqⱡi ‘it First Nation)Toquaht NationTsal'alh (also known as Seton Lake Indian Band)Tsay Keh Dene First NationTs'kw'aylaxw First Nation (also known as Pavilion IndianBand)Tŝideldel First Nation (formerly known as Alexis Creek)Ucluelet First Nation (Yuułuʔiłʔatḥ Government)Upper Nicola First NationUpper Similkameen First NationWestbank First NationWet'Suwet'En First NationWhispering Pines/Clinton Indian Band613559723718632593Williams Lake First Nation719Xatśūll First Nation (formerly known as Soda Creek IndianBand)Xaxli'p (also known as Fountain Indian Band)Xeni Gwet'in First Nation GovernmentXwisten (also known as Bridge River Indian Band)Yunesit'in First NationDates of Water AdvisoryJan 01, 2000 - Jun 07, 2002Nov 01, 2005 – Mar 09, 2011Mar 13, 2012 - Apr 01, 2019Jan 24, 2013 - Jun 01, 2014I lived on thisImpacted First NationFROM: Month, YearI lived on thisImpacted First NationUNTIL: Month, YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , Year653688617712603666595609Mar 01, 1999 - Jun 20, 2021Nov 25, 2004 - Jun 20, 2021Aug 04, 2017 – Nov 01, 2018Jul 24, 2007 - Jun 20, 2021Jun 16, 2004 - May 02, 2008Oct 18, 2019 - Jun 20, 2021Oct 18, 2019 – Jun 20, 2021Mar 14, 2012 - Jun 20, 2021Jan 07, 2005 - Nov 16, 2018Oct 04, 2004 - Jun 20, 2021Sep 11, 2008 - Oct 25, 2010Mar 27, 2002 - Mar 31, 2014Jul 17, 2012 - Jun 20, 2021Sep 25, 2006 - Dec 01, 2008594Oct 13, 2004 - Jun 28, 2006Month , YearMonth , Year710668697599601725702Apr 01, 1999 - Oct 12, 2018May 20, 2014 - Jun 20, 2021Jul 19, 2005 - Jun 20, 2021May 17, 2018 - Jun 20, 2021Aug 05, 2008 - Nov 12, 2020Mar 13, 2012 - Mar 18, 2021Feb 20, 2007 - Jun 20, 2021Jul 01, 2000 – Jun 27, 2005Sep 09, 2005 – Jun 20, 2021Aug 08, 2001 - Sep 27, 2002Sep 17, 2004 – Nov 04, 2005Jul 22, 2009 - Jun 20, 2021May 01, 2001 - Jun 20, 2021Nov 19, 2012 - Jun 20, 2021Apr 01, 1999 - Sep 30, 2002Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearI lived on thisImpacted First NationUNTIL: Month, Year608716592714590717Dates of Water AdvisoryI lived on thisImpacted First NationFROM: Month, YearBeren’s River First Nation266Jul 01, 2005 - Aug 21, 2006Month , YearMonth , YearCanupawakpa Dakota Nation289Mar 26, 2014 - Sep 28, 2018Month , YearMonth , YearFox Lake Cree Nation305Nov 28, 2014 - Dec 02, 2015Month , YearMonth , YearGod's Lake Narrows First Nation296Apr 24, 2005 - Jul 29, 2019Month , YearMonth , YearHollow Water First NationKinonjeoshtegon First Nation (also known as Jackhead First263Dec 20, 2016 - May 02, 2018Month , YearMonth , Year268Jul 07, 2016 - Jun 22, 2018Month , YearMonth , YearLake Manitoba First Nation271Month , YearMonth , YearLittle Grand Rapids First Nation270Jun 23, 2014 - Mar 23, 2016Apr 06, 2016 – May 08, 2017Jun 13, 2019 – Dec 23, 2020Aug 17, 2004 - Nov 16, 2005Month , YearMonth , YearLittle Saskatchewan First Nation274Sep 26, 2019 – Mar 23, 2021Month , YearMonth , YearLong Plain First Nation287Jul 22, 2016 - Feb 08, 2018Month , YearMonth , YearPauingassi First Nation327Month , YearMonth , YearMonth , YearMonth , YearManitobaFirst Nation /Band NumberFirst NationNation)Pine Creek First Nation282Sep 24, 2014 - Mar 16, 2018Apr 09, 2019 - Apr 17, 2019Aug 24, 2012 - Apr 08, 2019May 01, 2003 - May 29, 2004Month , YearMonth , YearSapotaweyak Cree NationSagkeeng First Nation (also known as Fort Alexander314Jul 10, 2019 - May 20, 2021Month , YearMonth , Year262Aug 05, 2016 - Mar 09, 2018Month , YearMonth , YearShamattawa First Nation307Dec 06, 2018 - Jun 20, 2021Month , YearMonth , YearTataskweyak Cree Nation306May 17, 2017 - Jun 20, 2021Month , YearMonth , YearPinaymootang First Nation (formerly known as FairfordFirst Nation)Indian Band)272First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 8 of 20

ManitobaFirst Nation /Band NumberFirst NationWuskwi Sipihk First Nation324New BrunswickFirst Nation /Band NumberFirst NationI lived on thisImpacted First NationFROM: Month, YearI lived on thisImpacted First NationUNTIL: Month, YearMonth , YearMonth , YearDates of Water AdvisoryI lived on thisImpacted First NationFROM: Month, YearI lived on thisImpacted First NationUNTIL: Month, YearDates of Water AdvisoryOct 01, 2001 - Jan 14, 2005Apr 24, 2014 – Jul 30, 2020Buctouche MicMac Band (also known as Tjopogtotjg)4Jun 10, 2010 - Feb 14, 2014Month , YearMonth , YearEel Ground First NationFort Folly First NationIndian Island First NationPabineau First NationTobique First Nation (Neqotkuk)Welamukotuk First Nation (also known as Oromocto First79101316Oct 08, 2008 - Apr 10, 2019Mar 06, 2002 - May 24, 2005Apr 07, 2005 - Jul 08, 2016Jun 01, 2005 - Jul 14, 2016Jul 19, 2007 - May 24, 2011Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , Year12Aug 12, 2008 - Nov 27, 2009Month , YearMonth , YearWoodstock First Nation17Mar 01, 2005 - May 01, 2007Month , YearMonth , YearI lived on thisImpacted First NationFROM: Month, YearI lived on thisImpacted First NationUNTIL: Month, YearMonth , YearMonth , YearDates of Water AdvisoryI lived on thisImpacted First NationFROM: Month, YearI lived on thisImpacted First NationUNTIL: Month, YearNation)Newfoundland and LabradorFirst NationMiawpukek First NationFirst Nation / BandNumber47First Nation / BandNumberNova ScotiaFirst NationDates of Water AdvisoryOct 08, 2008 - Sep 06, 2011Sep 10, 2014 – Jun 13, 2018Millbrook First Nation27Sep 15, 2006 - Feb 04, 2013Month , YearMonth , YearPotlotek First Nation (formerly known as Chapel Island)22Feb 13, 2015 - May 27, 2016Month , YearMonth , YearI lived on thisImpacted First NationUNTIL: Month, YearDates of Water AdvisoryI lived on thisImpacted First NationFROM: Month, YearAlderville First NationAlgonquins Of Pikwàkanagàn First NationAnimakee Wa Zhing #37 (formerly known as Northwest160163May 29, 2013 - Feb 11, 2016Jul 07, 2008 - Jun 20, 2021Month , YearMonth , YearMonth , YearMonth , Year152Oct 10, 2000 - Sep 03, 2020Month , YearMonth , YearAnishinaabeg Of Naongashiing First NationAroland First NationAsubpeeschoseewagunk Netum Anishinabek (Grassy125242May 26, 2008 - Jun 20, 2021Sep 04, 2008 - Jun 20, 2021Month , YearMonth , YearMonth , YearMonth , Year149Mar 01, 2009 - Jun 20, 2021Month , YearMonth , YearAttawapiskat First NationBearskin Lake First NationBig Grassy First NationBiinjitiwaabik Zaaging Anishinaabek (also known as Rocky143207124Jan 01, 2009 -Jun 20, 2021Feb 21, 2002 - Jun 20, 2021Mar 01, 2017 - Apr 17, 2019Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , Year197Aug 10, 2015 - Aug 11, 2016Month , YearMonth , YearCat Lake First Nation216Month , YearMonth , YearChippewas of Georgina Island First NationChippewas of Nawash Unceded First Nation138122Month , YearMonth , YearMonth , YearMonth , YearConstance Lake First Nation182Month , YearMonth , YearCouchiching First NationCurve Lake First NationDeer Lake First NationEabametoong First NationEagle Lake First Nation126161237183148Month , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearMonth , YearFort Severn First Nation215Month , YearMonth , YearHiawatha First Nation162Month , YearMonth , YearOntarioFirst Nation / BandNumberFirst NationAngle 37)Narrows First Nation)Bay First Nation)Feb 07, 2002 - Jul 27, 2006Oct 13, 2006 – Dec 17, 2018Apr 24, 2017 - Jun 20, 2021Jan 21, 2019 - Jun 20, 2021Jul 25, 2010 - Jul 03, 2012Apr 10, 2014 – Sep 26, 2016Apr 05, 2004 - Oct 03, 2005Aug 14, 2015 - Jun 06, 2018Nov 01, 2001 - Jun 20, 2021Aug 01, 2001 - Jun 20, 2021Sep 20, 2002 - Aug 31, 2009Jul 01, 2001 - Dec 01, 2003Feb 04, 2019 – Sep 25, 2020Jul 07, 2008 - Feb 28, 2019First Nations Drinking Water Settlement – Individual Class Member Claim Form – Page 9 of 20

Dates of Water AdvisoryI lived on thisImpacted First NationFROM: Month, YearKashechewan Cree First NationKeewaywin First Nation243325Aug 12, 2003 - Jun 23, 2006Jun 23, 2004 - Apr 23, 2008Month , YearMonth , YearMonth , YearMonth , YearKiashke Zaaging Anishinaabek (also known as Gull Bay FirstNation)188Apr 30, 2009 - Jun 20, 2021Month , YearMonth , YearKingfisher First Nation212Oct 22, 2004 - Sep 08, 2009Month , YearMonth , Year209Jul 26, 2001 - Apr 16, 2003Nov 18, 2005 – Aug 16, 2010Month , YearMonth , YearFeb 06, 2017 - Oct 25, 2018Jan 01, 1999 - Jan 07, 2020Jul 18, 2005 - Jun 20, 2021Aug 01, 2001 - Apr 20, 2007Aug 22, 2013

First Nations Drinking Water Settlement - Individual Class Member Claim Form - Page 1 of 20 . Claim Form for Individuals . The First Nations Drinking Water Settlement will compensate members of First Nations that experienced long-term drinking water advisories while living on an Impacted First Nation.* You might not need to fill out this form.