Class Action Opt-Out Notice

CLASS ACTION OPT-OUT NOTICE

SCOPE GATE — COMPLETE BEFORE USE

Federal Rule of Civil Procedure 23(c)(2)(B) requires a court-directed notice for a Rule 23(b)(3) class, including the time and manner for requesting exclusion. For a proposed settlement class under Rule 23(b)(3), the court-approved notice likewise controls. Rule 23(e)(4) does not create an automatic second opt-out right in every settlement; if a class was previously certified under Rule 23(b)(3), the court may condition settlement approval on a new exclusion opportunity.

Do not use this form unless the actual notice or order authorizes exclusion and every item below is copied exactly from that source.

REQUEST FOR EXCLUSION FROM CLASS OR SETTLEMENT CLASS

[________________________________] v. [________________________________]

Case No. [________________________________]

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

REQUEST FOR EXCLUSION (OPT-OUT) FORM

IMPORTANT: PLEASE READ BEFORE COMPLETING THIS FORM

By submitting this Request for Exclusion, you are asking to be excluded from the class identified in the controlling notice or order. The request is effective only if it is permitted, complete, timely, signed, and delivered in the manner the court approved.

IF THE REQUEST IS VALID, THE CASE-SPECIFIC NOTICE OR ORDER MAY PROVIDE THAT:

• You will not receive class or settlement benefits.
• You will not be bound by the class judgment as to the claims and parties described in the order.
• You will not give the settlement release identified in the notice, although another release, judgment, limitations period, or defense may still affect an individual claim.
• You may retain the ability to pursue an individual claim, subject to all applicable deadlines, defenses, costs, fee rules, and court requirements.

IF YOU DO NOT OPT OUT:

• The binding effect is determined by the certification order, Rule 23(c)(3), the settlement and release, and the final judgment.
• Eligibility for a payment or other benefit may require a separate, timely claim form.

DEADLINE TO OPT OUT: [__/__/____]

This request must be [POSTMARKED / RECEIVED / ELECTRONICALLY SUBMITTED / OTHER] by [TIME AND TIME ZONE] on the deadline above, exactly as the controlling notice or order requires.

SECTION 1: YOUR INFORMATION

Complete the form in the medium and format authorized by the controlling notice or order.

Full Legal Name:

First Name: [________________________________]

Middle Name: [________________________________]

Last Name: [________________________________]

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

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

[________________________________]

Current Mailing Address:

Street Address: [________________________________]

Apartment/Unit #: [________________________________]

City: [________________________________]

State: [________________________________]

ZIP Code: [________________________________]

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

Contact Information:

Daytime Telephone: [________________________________]

Email Address: [________________________________]

SECTION 2: CLASS MEMBERSHIP INFORMATION

To request exclusion, you must be a member of the Settlement Class.

The exact court-approved class definition is:

[PASTE THE EXACT CLASS DEFINITION FROM THE CONTROLLING NOTICE OR ORDER]

Please confirm that you are a member of the Settlement Class:

☐ Yes, I am a member of the Settlement Class because I [________________________________]

Please provide information supporting your class membership:

[________________________________]

[________________________________]

[________________________________]

SECTION 3: REQUEST FOR EXCLUSION

I hereby request to be excluded from [EXACT CLASS OR SETTLEMENT CLASS NAME] in [CASE NAME], Case No. [________________________________], to the extent authorized by the controlling notice and order.

I understand that by requesting exclusion:

☐ The consequences of exclusion are controlled by the actual notice, order, settlement, release, and judgment—not by this template.

☐ If my request is valid, I will not receive the class or settlement benefits identified in the notice.

☐ If my request is valid, I will not be bound as a class member by the judgment or settlement release to the extent stated in the controlling documents.

☐ Any individual claim remains subject to applicable limitations periods, tolling rules, other releases or judgments, defenses, proof requirements, fees, costs, and procedural law.

☐ I should obtain legal advice about both exclusion and any individual claim before the deadline.

SECTION 4: REASON FOR OPT-OUT (OPTIONAL)

Complete this section only if the controlling notice or order requests or permits a reason. Do not add facts that are not required without legal review.

[________________________________]

[________________________________]

[________________________________]

[________________________________]

SECTION 5: ATTORNEY INFORMATION (IF APPLICABLE)

Are you represented by an attorney in connection with claims related to this matter?

☐ No, I am not represented by an attorney.

☐ Yes, I am represented by the following attorney:

Attorney Name: [________________________________]

Firm Name: [________________________________]

Address: [________________________________]

City, State, ZIP: [________________________________]

Telephone: [________________________________]

Email: [________________________________]

SECTION 6: CERTIFICATION AND SIGNATURE

By signing below, I certify that:

1. I have read and understand the controlling class notice and exclusion instructions.

2. I am a member of the Settlement Class.

3. I voluntarily request exclusion from the exact class identified above.

4. I understand the consequences of my request for exclusion as described above.

5. The information I have provided in this form is true and correct to the best of my knowledge.

6. I have followed the signature, representative-capacity, identifier, and submission requirements stated in the controlling notice or order.

SIGNATURE:

[________________________________]
Signature

[________________________________]
Printed Name

[__/__/____]
Date

SECTION 7: SUBMISSION INSTRUCTIONS

Submit This Form Using an Authorized Method

☐ Mail to: [________________________________]

☐ Courier to: [________________________________]

☐ Upload at: [________________________________]

☐ Email to: [________________________________]

☐ Other court-approved method: [________________________________]

Deadline:

Your Request for Exclusion must be [POSTMARKED / RECEIVED / ELECTRONICALLY SUBMITTED / OTHER] by [TIME / TIME ZONE] on [__/__/____].

A late, incomplete, unsigned, misdirected, or otherwise noncompliant request may be ineffective unless the court permits correction, cure, or late exclusion. Follow the actual notice and preserve proof of submission.

FREQUENTLY ASKED QUESTIONS ABOUT OPTING OUT

1. What happens if I opt out?

If the request is valid, the consequences are those stated in the controlling notice, settlement, order, and judgment. They commonly include exclusion from class benefits and from the specified class judgment or settlement release, but the exact scope must be copied from the case documents.

2. Can I still submit a claim if I opt out?

Usually a person cannot both be excluded and receive a benefit reserved for participating class members, but the controlling settlement and order decide the issue. Do not submit inconsistent forms without legal review.

3. Can I change my mind after I opt out?

The controlling notice or order determines whether and how an exclusion request may be withdrawn, corrected, or cured. Do not assume that withdrawal is either allowed or prohibited.

4. If I opt out, can I sue the Defendant on my own?

If the request is valid, you may retain an individual claim to the extent it is not otherwise barred, released, adjudicated, or time-barred. You should be aware that:

• There may be statute of limitations issues
• Individual litigation can be expensive and time-consuming
• There is no guarantee of recovery in individual litigation
• You should consult with an attorney before deciding to pursue individual claims

5. If I opt out, will I be bound by the Settlement?

The controlling documents determine the answer. A valid exclusion request generally removes the requester from the class judgment and settlement release to the extent the order specifies; it does not erase unrelated judgments, releases, deadlines, or defenses.

6. Should I opt out?

This is a personal decision that depends on your individual circumstances. Factors to consider include:

• The amount you might receive from the Settlement
• The strength of your individual claims
• The cost of pursuing individual litigation
• The statute of limitations for your claims
• Your willingness to participate in potentially lengthy litigation

We strongly recommend that you consult with an attorney before deciding whether to opt out.

7. Do I need a lawyer to opt out?

The controlling notice states who may sign and submit the request. A person may often submit a request without counsel, but representative, entity, minor, estate, or incapacity issues may require additional authority. Legal advice is strongly recommended.

8. What if I do nothing?

The result of doing nothing depends on the certified class, notice, settlement, claim process, release, and judgment. For a Rule 23(b)(3) class, a person who falls within the class definition and does not validly request exclusion may be included in the class judgment under Rule 23(c)(3)(B). A separate claim form may be required for benefits.

QUESTIONS?

If you have questions about the Settlement or about opting out, you may:

Visit the Settlement Website:
[________________________________]

Call the Settlement Administrator:
[________________________________] (Toll-Free)

Write to the Settlement Administrator:

[________________________________] Settlement
[________________________________]
[________________________________]

Contact Class Counsel:

[________________________________]
[________________________________]
[________________________________]
Email: [________________________________]

Use only the contacts authorized by the actual notice. Do not contact the assigned judge directly; follow any instructions concerning the clerk, settlement administrator, or class counsel.

IMPORTANT DEADLINES

CHECKLIST BEFORE SUBMISSION

Before submitting your Request for Exclusion, review this checklist:

☐ I have completed all required fields in Sections 1-3.

☐ I have confirmed that I am a member of the Settlement Class in Section 2.

☐ I have read and understood the consequences of opting out in Section 3.

☐ I have signed and dated the Certification in Section 6.

☐ I have made a copy of this form for my records.

☐ I am using an authorized submission method and will satisfy the stated postmark, receipt, electronic-submission, or other deadline.

☐ I have preserved proof of mailing, delivery, upload, or other submission.

FOR SETTLEMENT ADMINISTRATOR USE ONLY

Sources and References

• Federal Rules of Civil Procedure, current through December 1, 2025 — official U.S. Courts PDF
• Federal Rule of Civil Procedure 23 — official current rules page
• Pending federal rules amendments — official U.S. Courts page

Use this form only after counsel confirms that the court-authorized notice and order permit exclusion and that every case-specific instruction above is exact.