CLASS ACTION OPT-OUT NOTICE

REQUEST FOR EXCLUSION FROM CLASS ACTION SETTLEMENT

[________________________________] 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 choosing to OPT OUT of the Class Action Settlement in the above-captioned matter. This means:

IF YOU OPT OUT:
- You will NOT receive any payment or benefit from this Settlement
- You will NOT release any claims against the Defendant
- You will keep your right to sue the Defendant separately on your own
- You will be responsible for your own attorney's fees and costs if you pursue individual litigation

IF YOU DO NOT OPT OUT:
- You will remain a member of the Settlement Class
- You may be eligible to receive a payment if you submit a valid Claim Form
- You will release all claims covered by the Settlement
- You will be bound by the Court's final judgment

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

This form must be POSTMARKED by the deadline above.

SECTION 1: YOUR INFORMATION

Please print clearly in blue or black ink.

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 Settlement Class includes:

All persons in the United States who [________________________________] during the period from [__/__/____] to [__/__/____].

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 the Settlement Class in the matter of [________________________________] v. [________________________________], Case No. [________________________________].

I understand that by requesting exclusion:

☐ I will NOT receive any payment or benefit from this Settlement.

☐ I will NOT be bound by any judgment entered in this case.

☐ I will NOT release any claims against the Defendant.

☐ I will retain my right to pursue my own individual lawsuit against the Defendant.

☐ If I choose to pursue individual litigation, I will be responsible for my own attorney's fees and costs.

☐ The statute of limitations for my individual claims may be affected, and I should consult with an attorney regarding applicable deadlines.

SECTION 4: REASON FOR OPT-OUT (OPTIONAL)

You are NOT required to provide a reason for your request for exclusion. However, if you wish to explain your decision, you may do so below:

[________________________________]

[________________________________]

[________________________________]

[________________________________]

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 Notice of Class Action Settlement.

2. I am a member of the Settlement Class.

3. I voluntarily request to be excluded from the Settlement Class.

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 not previously submitted a Claim Form in this Settlement (or if I have, I hereby withdraw it).

SIGNATURE:

[________________________________]
Signature

[________________________________]
Printed Name

[__/__/____]
Date

SECTION 7: SUBMISSION INSTRUCTIONS

Mail This Form To:

[________________________________] Settlement
Exclusion Requests
[________________________________]
[________________________________]
[________________________________]

Deadline:

Your Request for Exclusion must be POSTMARKED by [__/__/____].

Requests for exclusion that are not postmarked by this deadline will not be honored, and you will remain a member of the Settlement Class.

FREQUENTLY ASKED QUESTIONS ABOUT OPTING OUT

1. What happens if I opt out?

If you opt out, you will not be part of the Settlement Class. You will not receive any payment from the Settlement, and you will not release any claims against the Defendant. You will keep your right to sue the Defendant on your own.

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

No. If you opt out, you cannot submit a claim for payment from the Settlement. The deadline to opt out and the deadline to submit a claim are separate.

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

Generally, no. Once you submit a valid Request for Exclusion by the deadline, it is final. You should carefully consider your decision before opting out.

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

Yes. If you opt out, you retain the right to pursue your own individual lawsuit against the Defendant. However, you will be responsible for your own attorney's fees and costs. 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?

No. If you opt out, you will not be bound by the Settlement Agreement or any judgment in this case. You will not release any claims against the Defendant.

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?

No. You do not need a lawyer to opt out. However, you may wish to consult with a lawyer about whether opting out is the right decision for you.

8. What if I do nothing?

If you do nothing, you will remain a member of the Settlement Class. If you want to receive a payment, you must submit a Claim Form by the deadline. If you do not submit a Claim Form, you will not receive a payment, but you will still release your claims against the Defendant.

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: [________________________________]

DO NOT CONTACT THE COURT OR THE CLERK'S OFFICE FOR INFORMATION ABOUT THE SETTLEMENT.

IMPORTANT DEADLINES

CHECKLIST BEFORE MAILING

Before mailing your Request for Exclusion, please 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 mailing this form in time to be postmarked by [__/__/____].

FOR SETTLEMENT ADMINISTRATOR USE ONLY

This form was authorized by the United States District Court for the [________________________________] District of [________________________________]. Opting out of a class action settlement is an important legal decision. If you are unsure whether to opt out, you should consult with a qualified attorney.