CLAIM FORM - CLASS ACTION SETTLEMENT

[________________________________] v. [________________________________]

Case No. [________________________________]

United States District Court for the [________________________________] District of [________________________________]

PROOF OF CLAIM AND RELEASE FORM

DEADLINE TO SUBMIT CLAIM: [__/__/____]

You may submit this Claim Form online at: [________________________________]

INSTRUCTIONS

Please read these instructions carefully before completing the Claim Form.

1. To be eligible for a payment from the Settlement, you must complete and submit this Claim Form by the deadline shown above.

2. Print clearly in blue or black ink. You may also complete this form online.

3. Provide all requested information. Incomplete or illegible forms may delay processing or result in denial of your claim.

4. Keep a copy of your completed Claim Form and any documents you submit for your records.

5. If you need assistance completing this form, call [________________________________] or visit [________________________________].

PART A: CLAIMANT INFORMATION

A1. Your Full Legal Name:

First Name: [________________________________]

Middle Name: [________________________________]

Last Name: [________________________________]

Suffix (Jr., Sr., III, etc.): [____]

A2. Any Other Names Used (maiden name, former names, aliases):

[________________________________]

A3. Current Mailing Address:

Street Address: [________________________________]

Apartment/Unit #: [________________________________]

City: [________________________________]

State: [________________________________]

ZIP Code: [________________________________]

Country (if outside U.S.): [________________________________]

A4. Contact Information:

Daytime Telephone: [________________________________]

Evening Telephone: [________________________________]

Email Address: [________________________________]

A5. Date of Birth: [__/__/____]

A6. Last Four Digits of Social Security Number: XXX-XX-[____]
(Required for tax reporting purposes if your payment exceeds $600)

PART B: CLASS MEMBERSHIP INFORMATION

To receive a payment, you must demonstrate that you are a member of the Settlement Class.

B1. Did you [________________________________] during the period from [__/__/____] to [__/__/____]?

☐ Yes
☐ No

If you answered "No," you are NOT a member of the Settlement Class and are not eligible to receive a payment. Do not submit this Claim Form.

B2. Please provide the following information about your [________________________________]:

Date(s) of [purchase/transaction/service]: [________________________________]

Location(s): [________________________________]

Amount(s) Paid: $[________________________________]

[________________________________]

B3. How did you [________________________________]?

☐ [________________________________]
☐ [________________________________]
☐ [________________________________]
☐ Other: [________________________________]

B4. Product/Service Information (if applicable):

Product Name/Model: [________________________________]

Serial Number (if known): [________________________________]

Purchase Price: $[________________________________]

Place of Purchase: [________________________________]

PART C: PROOF OF CLASS MEMBERSHIP

You must provide documentation to support your claim. Acceptable forms of documentation include:

☐ Receipt(s)
☐ Credit card or bank statement(s) showing the purchase/transaction
☐ Invoice(s)
☐ Confirmation email(s)
☐ Product packaging or UPC code
☐ Photograph of product
☐ Contract or agreement
☐ [________________________________]
☐ Other documentation: [________________________________]

Attach copies of your supporting documentation to this Claim Form.

PART D: CLAIM AMOUNT / TIER SELECTION

[Option A - Single Tier:]

D1. Based on your class membership, you are eligible to receive a pro rata share of the Net Settlement Fund, estimated at approximately $[________________________________] per claimant.

[Option B - Multiple Tiers:]

D1. Please select the tier that applies to you:

☐ Tier 1: [________________________________]
Estimated Payment: Up to $[________________________________]

☐ Tier 2: [________________________________]
Estimated Payment: Up to $[________________________________]

☐ Tier 3: [________________________________]
Estimated Payment: Up to $[________________________________]

D2. If you are claiming multiple [purchases/transactions], please list each one:

Attach additional pages if necessary.

PART E: PAYMENT INFORMATION

E1. How would you like to receive your payment?

☐ Check - Mailed to the address in Part A

☐ Electronic Payment (Direct Deposit/ACH)

Bank Name: [________________________________]

Routing Number: [________________________________]

Account Number: [________________________________]

Account Type: ☐ Checking ☐ Savings

☐ Electronic Payment (PayPal, Venmo, or similar)

Service: [________________________________]

Account Email/Username: [________________________________]

E2. Alternate Payee (if different from Claimant):

Complete only if the payment should be made to someone other than the Claimant (e.g., estate, guardian, etc.)

Name: [________________________________]

Relationship to Claimant: [________________________________]

Address: [________________________________]

PART F: CERTIFICATION AND SIGNATURE

By signing below, I certify under penalty of perjury that:

1. I have read and understand the Notice of Class Action Settlement.

2. I am a member of the Settlement Class as defined in the Notice.

3. The information provided in this Claim Form is true and correct to the best of my knowledge.

4. I have not submitted any other claim in connection with this Settlement, and I am not excluded from the Settlement Class.

5. I have not assigned or transferred any claim relating to this Settlement to any other person or entity.

6. I understand that by submitting this Claim Form, I am agreeing to be bound by the terms of the Settlement Agreement and to release all Released Claims against the Released Parties as described in the Settlement Agreement and Notice.

7. I understand that the Claims Administrator may request additional documentation to verify my claim, and I agree to provide such documentation promptly if requested.

8. I agree to notify the Claims Administrator promptly if my address or other contact information changes.

SIGNATURE:

[________________________________]
Signature of Claimant (or Authorized Representative)

[________________________________]
Printed Name

[__/__/____]
Date

If signed by an Authorized Representative:

[________________________________]
Name of Authorized Representative

[________________________________]
Relationship to Claimant / Title

[________________________________]
Telephone Number

PART G: SUBMISSION INSTRUCTIONS

Submit Online:

Visit [________________________________] to submit your claim electronically.

Submit by Mail:

Mail your completed Claim Form and supporting documentation to:

[________________________________] Settlement
Claims Administrator
[________________________________]
[________________________________]
[________________________________]

Deadline:

Your Claim Form must be submitted online or postmarked by [__/__/____].

Claims submitted after the deadline will not be accepted unless excused by the Court.

CHECKLIST BEFORE SUBMITTING

Please review this checklist before submitting your Claim Form:

☐ I have completed all required fields in Parts A through E.

☐ I have attached copies of my supporting documentation (keep originals for your records).

☐ I have signed and dated the Certification in Part F.

☐ I have made a copy of my completed Claim Form for my records.

☐ I am submitting my claim by the deadline: [__/__/____]

QUESTIONS?

Settlement Website: [________________________________]

Toll-Free Number: [________________________________]

Email: [________________________________]

Mailing Address:

[________________________________] Settlement
Claims Administrator
[________________________________]
[________________________________]

REMINDER OF IMPORTANT DATES

FOR CLAIMS ADMINISTRATOR USE ONLY

This Claim Form was authorized by the United States District Court for the [________________________________] District of [________________________________]. You must submit this form to receive a payment from the Settlement. This is not a solicitation from a lawyer.