Claim Form - Class Action Settlement

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: [__/__/____]

Approved submission method: [________________________________]

INSTRUCTIONS

Please read these instructions carefully before completing the Claim Form.

1. If the approved Settlement requires a claim to receive payment, complete and submit this form by the deadline stated in its notice.

2. If submitting on paper, print clearly. Use an online channel only if the approved claims procedure offers one.

3. Provide the information required by the approved claims procedure. Incomplete or illegible forms may delay review or affect a claim as the approved procedure provides.

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. Taxpayer information, only if the approved claim process requires it: [DESCRIBE THE SECURE COLLECTION METHOD OR "NOT REQUESTED ON THIS FORM"]. Do not put a Social Security number on this form unless the approved process specifically calls for it and provides a secure submission channel.

PART B: CLASS MEMBERSHIP INFORMATION

Provide the information that the approved Settlement requires to establish eligibility for the relief requested.

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

☐ Yes
☐ No

If you answered "No," compare your circumstances with the complete class definition and any alternative eligibility route in the approved notice before deciding whether to submit a claim.

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

Provide only documentation required by the approved Settlement and claim instructions. If proof is required, accepted examples may 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 supporting documentation only if the approved claims procedure requires them.

PART D: CLAIM AMOUNT / TIER SELECTION

[Option A - Single Tier:]

D1. If the approved Settlement provides a pro rata payment, state the estimated amount or calculation: $[________________________________].

[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. If the approved Settlement offers a payment choice, select an available method:

☐ Check - Mailed to the address in Part A

☐ Electronic Payment (Direct Deposit/ACH)

Enter bank details only through the approved secure payment channel: [________________________________]

☐ 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 the following statements to the best of my knowledge:

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

2. I request review of my eligibility under the Settlement Class definition and approved claims procedure.

3. The information provided in this Claim Form is true and correct.

4. Other claims or exclusions relevant under the approved claims procedure: [________________________________].

5. Any assignment or representative authority relevant under the approved claims procedure: [________________________________].

6. I understand that any release or binding effect is governed by the Court's approved Settlement Agreement, notice, and orders, including any applicable exclusion right. Submitting this form does not by itself create a broader release.

7. I understand that the Claims Administrator will review this claim under the approved procedure and may request information permitted by that procedure.

8. I will notify the Claims Administrator if my address or other contact information changes before the claim is resolved.

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:

If offered by the approved procedure, visit [________________________________] to submit your claim electronically.

Submit by Mail:

If offered by the approved procedure, mail your completed Claim Form and required supporting documentation to:

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

Deadline:

Submission deadline and controlling receipt/postmark rule from the approved notice: [________________________________].

The approved Settlement Agreement, notice, and claims procedure determine how late claims are handled.

CHECKLIST BEFORE SUBMITTING

Please review this checklist before submitting your Claim Form:

☐ I have completed the fields required by the approved claims procedure.

☐ I have attached any required supporting documentation (keep originals for your records).

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

☐ I have kept 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

Use this form only if it matches the claim form and instructions approved for the identified settlement. The approved settlement controls whether a claim form is required for payment. This is not a solicitation from a lawyer.