Common use of ATTESTATION AND SIGNATURE Clause in Contracts

ATTESTATION AND SIGNATURE. I certify under penalty of perjury under the laws of the United States that the information I am providing in this claim form is true and correct, and that I am the cardholder of the card identified in my response to Question Two, above. Name: Signature: Date: If you have questions, please contact the Settlement Administrator at 0-000-000-0000 or visit xxx.XXXxxxxxxxxx.xxx. EXHIBIT B PROPOSED FINAL ORDER AND FINAL JUDGMENT IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WISCONSIN SANGER POWERS and XXXXXX XXXX,individually and on behalf of all others similarly situated, Plaintiffs, v. FILTERS FAST, LLC, Defendant Case No. 3:20-cv-00982-jdp [PROPOSED] FINAL ORDER A Final Approval Hearing was held before this Court on , 2021 to consider, among other things, whether the Settlement Agreement and Release dated (the “Settlement Agreement”) (ECF No. ), including the exhibits attached thereto, between Settlement Class Representatives Sanger Powers, Xxxxxx Xxxx, Xxxxxxxx XxXxxxxx, Xxxxx Xxxx, and Xxxxx Xxxxxxxxxxx, on behalf of themselves and the Settlement Class, and Defendant Filters Fast, LLC (“Filters Fast”), represents a fair, reasonable, and adequate settlement of this case (“the Action”), as well as the amount to be paid to Class Counsel as fees and costs for prosecuting the Action, and the amount to be paid to the Settlement Class Representatives as Service Awards. Based on the Settlement Agreement, the Settlement Class Representatives’ Motion for Final Approval of Class Action Settlement (ECF No. ), the Settlement Class Representatives’ Motion for an Award of Attorneys’ Fees and Expenses and Service Awards for Settlement Class Representatives (ECF No. ), the submissions of the Settlement Class Representatives and Filters Fast in support of final approval of the settlement, and good cause appearing based on the record, the Court ORDERS, ADJUDGES AND DECREES as follows:

ATTESTATION AND SIGNATURE. I certify under penalty of perjury under the laws of the United States that the information I am providing in this claim form is true and correct, and that I am the cardholder of the card identified in my response to Question Two, above. Name: Signature: Date: If you have questions, please contact the Settlement Administrator at 0-000-000-0000 or visit xxx.XXXxxxxxxxxx.xxx. EXHIBIT B PROPOSED FINAL ORDER AND FINAL JUDGMENT IN THE UNITED STATES DISTRICT COURT FOR THE WESTERN DISTRICT OF WISCONSIN SANGER POWERS XXXXXX XXXXXX and XXXXXX XXXX,individually and on behalf of all others similarly situated, Plaintiffs, v. FILTERS FAST, LLC, Defendant Case No. 3:20-cv-00982-jdp [PROPOSED] FINAL ORDER A Final Approval Hearing was held before this Court on , 2021 to consider, among other things, whether the Settlement Agreement and Release dated (the “Settlement Agreement”) (ECF No. ), including the exhibits attached thereto, between Settlement Class Representatives Sanger PowersXxxxxx Xxxxxx, Xxxxxx Xxxx, Xxxxxxxx XxXxxxxx, Xxxxx Xxxx, and Xxxxx Xxxxxxxxxxx, on behalf of themselves and the Settlement Class, and Defendant Filters Fast, LLC (“Filters Fast”), represents a fair, reasonable, and adequate settlement of this case (“the Action”), as well as the amount to be paid to Class Counsel as fees and costs for prosecuting the Action, and the amount to be paid to the Settlement Class Representatives as Service Awards. Based on the Settlement Agreement, the Settlement Class Representatives’ Motion for Final Approval of Class Action Settlement (ECF No. ), the Settlement Class Representatives’ Motion for an Award of Attorneys’ Fees and Expenses and Service Awards for Settlement Class Representatives (ECF No. ), the submissions of the Settlement Class Representatives and Filters Fast in support of final approval of the settlement, and good cause appearing based on the record, the Court ORDERS, ADJUDGES XXXXXXXX AND DECREES as follows:

ATTESTATION AND SIGNATURE. I certify do hereby swear (or affirm), under penalty of perjury under the laws of the United States perjury, that the information I am providing in this claim form provided above is true and correct, accurate to the best of my knowledge and that the compensation I am claiming is based on losses I reasonably believe to the cardholder best of my knowledge were the result of the card identified in my response to Question Two, aboveCheckers Data Breach. Name: Signature: Date: If you have questions, please contact the Settlement Administrator at 0Case 8:19-000cv-01386-000VMC-0000 or visit xxx.XXXxxxxxxxxx.xxx. EXHIBIT B PROPOSED FINAL ORDER AND FINAL JUDGMENT IN THE UNITED STATES CPT Document 43-1 Filed 05/06/20 Page 68 of 81 PageID 000 XXXXXX XXXXXX DISTRICT COURT FOR THE WESTERN MIDDLE DISTRICT OF WISCONSIN SANGER POWERS FLORIDA TAMPA DIVISION XXXXXXXX XXXXXX and XXXXXX XXXX XXXX,individually and on behalf of all others similarly situated, PlaintiffsPlaintiff, v. FILTERS FASTCHECKERS DRIVE-IN RESTAURANTS, LLCINC.,a Delaware corporation, Defendant Defendant. Case No. 3:20.: 8:19-cv-00982cv-01386-jdp VMC-CPT Class Action [PROPOSED] FINAL APPROVAL ORDER A Final Approval Hearing was held AND JUDGMENT This matter came before this the Court on , 2021 to consider, among other things, whether the Settlement Agreement and Release dated (the “Settlement Agreement”) (ECF No. ), including the exhibits attached thereto, between Settlement Class Representatives Sanger Powers, Xxxxxx Xxxx, Xxxxxxxx XxXxxxxx, Xxxxx Xxxx, and Xxxxx Xxxxxxxxxxx, on behalf of themselves and the Settlement Class, and Defendant Filters Fast, LLC (“Filters Fast”), represents a fair, reasonable, and adequate settlement of this case (“the Action”), as well as the amount to be paid to Class Counsel as fees and costs for prosecuting the Action, and the amount to be paid to the Settlement Class Representatives as Service Awards. Based on the Settlement Agreement, the Settlement Class RepresentativesPlaintiffs’ Unopposed Motion for Final Approval of Class Action Settlement and entry of final judgment (ECF No“Motion”). On , the Court entered an Order preliminarily approving the proposed Settlement pursuant to the terms of the Parties’ Settlement Agreement and directing that notice be given to the Settlement Class (the “Preliminary Approval Order”). On , pursuant to the notice requirements set forth in the Settlement Agreement and the Preliminary Approval Order, the Settlement Class Representatives’ Motion for an Award was notified of Attorneys’ Fees and Expenses and Service Awards for the terms of the proposed Settlement Agreement, of the right of Settlement Class Representatives (ECF NoMembers to opt-out, and the right of Settlement Class Members to object to the Settlement Agreement and to be heard at a Final Approval Hearing. )On , the submissions Court held a Final Approval Hearing to determine, inter alia: (1) whether the terms and conditions of the Settlement Agreement are fair, reasonable, and adequate for the release of the claims contemplated by the Settlement Agreement; and (2) whether judgment should be entered dismissing this action with prejudice. Therefore, the Court is satisfied that Settlement Class Representatives and Filters Fast Members were properly notified of their right to appear at the Final Approval Hearing in support of final approval or in opposition to the proposed Settlement Agreement, the award of attorneys’ fees and costs to Class Counsel, and the payment of Service Awards to the Representative Plaintiffs. Having given an opportunity to be heard to all requesting persons in accordance with the Preliminary Approval Order, having heard the presentation of Class Counsel and counsel for Defendant, having reviewed all of the settlementsubmissions presented with respect to the proposed Settlement Agreement, having determined that the Settlement Agreement is fair, adequate, and reasonable, having considered the application made by Class Counsel for attorneys’ fees and costs and expenses, and the application for Service Awards to the Representative Plaintiffs, and having reviewed the materials in support thereof, and good cause appearing based on the record, the Court ORDERS, ADJUDGES appearing: THIS COURT FINDS AND DECREES as followsORDERS AS FOLLOWS: