TO RECEIVE A PAYMENT, YOU MUST COMPLETE AND SIGN THIS CLAIM FORM AND SUBMIT IT TO THE SETTLEMENT ADMINISTRATOR (SEE SUBMISSION INFORMATION BELOW) BY JULY 10, 2019
Please read this form carefully and follow the instructions below.
Step 1: Provide the requested information.
Step 2: Sign the certification.
YOU ARE ONLY ENTITLED TO SUBMIT A CLAIM FORM IF YOU ARE A MEMBER OF ONE OR MORE OF THE SETTLEMENT CLASSES. See the Long Form Notice here or call 1-833-402-1723 if you have questions as to whether you are a member of the Settlement Classes.
Each Settlement Class Member is entitled to submit only one claim. Your claim may be rejected if you do not provide the information requested. Your claim will also be rejected if you do not sign the Claim Form.