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CLAIM FORM

 

Registration Page

Please Enter Your Information (All fields marked with an * are required)

To receive payment from the settlement, you must accurately complete this Claim Form and submit it no later than May 17, 2017.

Complete the following.

*First Name: 

 

Middle Initial: 

*Last Name: 

 

*Address 1: 

   

Address 2: 

 

*City: 

   

*State: 

 

*Zip: 

   
Day Telephone Number: 
 xxx-xxx-xxxx    

Evening Telephone Number: 

 xxx-xxx-xxxx  

Email Address: 

 

Disclaimer

IMPORTANT: THIS SITE IS ADMINISTERED BY AN ADMINISTRATION FIRM THAT HANDLES ALL ASPECTS OF THE SETTLEMENT. THIS IS THE ONLY AUTHORIZED WEBSITE FOR THIS SETTLEMENT. PLEASE DO NOT RELY UPON OTHER SITES THAT SET OUT DIFFERENT AND UNAUTHORIZED INFORMATION.

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