ONLINE Claim Registration Form

Claim Registration Form

THIS FORM MUST BE FULLY COMPLETED AND SUBMITTED TO THE CLAIMS ADMINISTRATOR BY APRIL 14, 2022.

By completing this Claim Registration Form for the Lake Manitoba Class Action Settlement, you declare that you are representing yourself, a farm, a business, a not-for-profit, as executor of an estate or represent another individual through a Power of Attorney.

A. Contact Information

Surname

First and Other Given Names

Business or Farm Name (if applicable)

Address

Address Line 2

City

Postal Code

Province

Country

Current Address

Property Address as at either: April 1, 2011, or May 1, 2011

Address

Address Line 2

City

Postal Code

Municipality Name / No.

Civic Address

Road No.

Telephone No.

Cell No.

Fax No.

Email Address

Social Insurance Number

Business Identification Number

B. Claimants Applying for Eligibility

Claimants applying for eligibility for the Class Action Settlement may include:

1. Claimants who applied to the Lake Manitoba Financial Assistance Program from 2011 to 2014 and:

a. Whose claim was rejected by the Province of Manitoba as not being eligible

b. Who received compensation for less than the amounts of their claim amounts or

c. Who has additional claim amounts that were not submitted since they did not meet the Lake Manitoba Financial Assistance Program criteria

and now meet the Class Action Settlement criteria.

2. Claimants who did not apply to the Lake Manitoba Financial Assistance Program and who meet the Class Action Settlement criteria.

3. Claimants who applied to the 2011 Lake Manitoba Financial Assistance Program and who received full compensation for the amounts of their claim amounts are not eligible for the Class Action Settlement.

C. Declaring Eligibility

I am registering my participation for the Lake Manitoba Class Action Settlement and declare that I have read the Class Action Settlement Eligibility Criteria and hereby declare I am eligible as follows (Check each box that applies):

As at May 1, 2011:

I was 18 years or older.

I owned or rented a Principal Residence or Non-Principal Residence located within 30 kilometres of Lake Manitoba.

I had an ownership interest in a Business or Not-for-Profit sole proprietorship, partnership, corporation, cooperative or commune that owned or rented property located within 30 kilometres of Lake Manitoba.

For Farm Claims, as at April 1, 2011:

I had an ownership interest in a Farm sole proprietorship, partnership, corporation, cooperative or commune that met the criteria listed at the bottom of this Claims Registration Form.

D. Personal, Property and Business Evidence

Please provide to the Claims Administrator the following applicable documents as Personal, Property and Business Evidence with your application.

Personal:

Government-issued identification with your name and current address (e.g. Drivers License)

Estate:

If you are filing this Claim Registration Form as the Executor of an Estate, provide a copy of the proof of Probate.

POA:

If you are filing this Claim Registration Form as the Power of Attorney on behalf of another individual, provide a copy of the executed Power of Attorney document.

I would like to upload my supporting documents. By checking this option, after you click the Submit Application button at the end of this form, the Upload Documents screen launch.

Property:

A document, for example, Land Deeds, Property Tax Assessments with the Education Provincial Tax Credit, Income Tax Returns, Homeowners' Insurance Policies with the applicable location address as at May 1, 2011.

Business / Farm / Not-for-Profit:

Financial Statements, Tax Returns, etc. with the applicable location address as at May 1, 2011.

Obtaining Supporting Evidence:

If your Property, Business or Farm information was filed with the Land Manitoba Financial Assistance Program administered by the Manitoba Agricultural Services Corporation (MASC), based on your authorization in completing and signing this Claim Registration Form, the Claims Administrator can obtain that supporting evidence.

Please obtain my supporting evidence from MASC.

Other:

Any other documentation supporting evidence your eligibility.

E. Payments from Lake Manitoba Financial Assistance Programs from 2011 to 2014

I personally, my business, farm, not-for-profit, the estate I represent or the individual I represent as their Power of Attorney applied to the Lake Manitoba Financial Assistance Program administered by the Manitoba Agricultural Services Corporation (MASC) or other:

(Check Applicable Box):

I applied for and received payment(s).

I applied for but did NOT receive any payment(s) from the Lake Manitoba Financial Assistance Program.

I did NOT apply for compensation from the Lake Manitoba Financial Assistance Program.

Unsure if any payments as compensation from the Lake Manitoba Financial Assistance Program were received.

I received Insurance proceeds from either Manitoba Public Insurance or any other insurance provider.

F. Eligible Losses

I declare that I believe I am eligible for compensation for the following losses beyond any amounts I may have received from the Lake Manitoba Financial Assistance Program:

Damage to Primary Residence, Seasonal Residence, Business or Farm Property

Farmland Damage or Herd Loss

Business / Not-for-Profit Entities Net Income Losses

Flood Cleanup and Mitigation

Moving / Storage / Accommodation Rental Expenses

Other, please list:

G. Next Steps

Upon submitting your Claim Registration Form by the filing deadline of April 14, 2022, you will be subsequently contacted by the Claims Administrator regarding your eligibility.

If you are eligible, you will receive additional documents that will be required to be completed for the Claims Administrator to assess any potential amounts you may be entitled to receive (if any) from the Lake Manitoba 2011 Flood Class Action Settlement Fund.

If you are advised that you are not eligible, you will be provided with the opportunity to submit, within a set timeframe, any additional information / documentation that you believe may assist the Claims Administrator in assessing your eligibility. Subsequently, the Claims Administrator will provide a final communication of your eligibility or ineligibility.

H. Communication with Claims Administrator

Please indicate the method of communication you prefer to receive from the Claims Administrator (select one only):

Email (input below)

Mail: name and current address listed on page one of this form

Mail: different name and address (input below)

Fax: number listed on page one of this form

Fax: different number (input below)

Email address

Address

Fax number

Email address 2

Address Line 2

City

Province

Postal Code

Country

I. Acknowledgement, Authorization and Declaration

As a Class Member, I acknowledge that:

By making this claim, I am subject to the terms of the Settlement Approval Order which limits my recovery to the amount that the Claims Administrator shall determine, having regard to the eligibility and compensation criteria that the Administrator shall apply.
I acknowledge that any decision of the Claims Administrator with regards to eligibility and/or compensation is final and is not subject to appeal or any review in any fashion.
That the criteria applied by the Claims Administrator are final and not subject to review or challenge or appeal.
Any recovery is limited to the Administrative Claim Process and any claims for payment, compensation or damages of any kind against the Government of Manitoba, the Claims Administrator, or Class Counsel other than recovery under the Administrative Claims Process are prohibited by terms of the Settlement.
If I do not submit a Claim Registration Form by the Claims Registration Deadline, my claim is barred and extinguished forever.
I hereby authorize the Government of Manitoba and/or the Agricultural Services Corporation to release any information relating to my Lake Manitoba Financial Assistance Program documentation and payments information (if any) to the Claims Administrator (Exchange Solutions Ltd.) for the purpose of determining my eligibility under the Lake Manitoba 2011 Flood Class Action Settlement Criteria. I understand that if I wish to revoke this consent, I must do so in writing. I acknowledge that this consent will remain in full force and effect until expressly revoked by me.
I hereby authorize the Claims Administrator to contact my Municipality or other government body to confirm ownership of any property as at May 1, 2011 that I am making a Claim.
I declare that the information given on this application is true and complete; and I acknowledge, agree and meet the Terms and Conditions of the Lake Manitoba 2011 Flood Class Action Settlement Criteria.
I declare that to my knowledge, I am the only person filing a Claim Registration Form for the properties, businesses, farm, not-for-profit or any other purpose(s) outlined in this form.
I acknowledge that the Claims Administrator has sole discretion in following the court-approved Lake Manitoba 2011 Flood Class Action Settlement criteria to request additional information, supporting documentation, etc.
I declare under penalty of the laws of the Province of Manitoba that the foregoing in this Claim Registration Form is true and correct.

Applicant Name

Date

Please use mouse or touch screen to complete signature.

Signature of Applicant

Please below before Submitting your Application.

Upon success completion and submission of your Claim Registration Form, you will receive an email confirming its submission.

If you are not redirected to the Upload Document DropBox, please click here after you have clicked the Submit Application button above and you will be redirected to the Upload Document DropBox screen or select the Upload Documents menu option above.

Questions

Please direct any questions you have regarding the Claim Registration Form to any one of the following:

Exchange Group

Lake Manitoba 2011 Class Action Settlement

Claims Administrator

Telephone: 1-204-947-7120 or 1-833-947-7120

Fax: 1-204-957-5195

Email: Questions@LakeManitobaFloodSettlement2021.com

Website: www.LakeManitobaFloodSettlement2021.com

Farm Claim Eligibility Criteria

For Farm Claims, as at April 1, 2011:

I had an ownership interest in a Farm sole proprietorship, partnership, corporation, cooperative or commune that:

Owned or leased Agricultural Land or a Farm Business located within 30 kilometres of Lake Manitoba;

Owned or leased the Eligible Land located within 30 kilometres of Lake Manitoba;

Owned or leased an Animal Premises used to house Evacuated Animals during the time period starting on April 1, 2011, and ending on October 31, 2012;

Was responsible for the cost of feeding the Eligible Animals which include:

Cattle, bison, elk, sheep, goats, llamas, alpacas, horses or pigs, others and

Located within 30 kilometres of Lake Manitoba; and

Meet either the following two criteria:

Were mature breeding animals owned or leased by the Eligible Participant, based on the number on December 31, 2010, or April 1, 2011, whichever is greater; or

Were other animals that the Eligible Participant was expected to graze on pasture, as determined by the Claims Administrator. This may be based on the greater of the number of such animals on April 1, 2011, or the average inventory that the Eligible Participant was responsible to feed during the summer grazing season from May 28 to October 15, 2010.