ATTESTATION & SIGNATURE. Each signature must be attested by the Corporate Officer (CO) or equivalent. Where the Corporate Officer is also a signer, we ask that the CO also provide a clear photocopy piece of photo ID to accompany the attestation. Print Attestation Title: Attestation Signature:
ATTESTATION & SIGNATURE. I swear and affirm under the laws of my state that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below. / / Signature Date Print Name *0000000000000* Your claim must be submitted online or postmarked by: CLAIM FORM FOR LIFESCAN LABS DATA INCIDENT AND BIPA SETTLEMENT Questions? Go to xxx.xxxxxxxxxxxxxx.xxx or call (XXX) XXX-XXXX. *73135* *CF* *Page 5 of 65* 73135 CF Page 5 of 65
ATTESTATION & SIGNATURE. I swear and affirm under the laws of my state that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below. / / Signature Date Print Name If your address changes or you need to make a future correction/update to the address you provide on this Claim Form, please visit the Contact section of the Settlement Website at xxx.XxxXxxxxXxxxXxxxxxxxxx.xxx and provide your updated address information. Make sure to include your Settlement Class Member ID and your phone number in case we need to contact you in order to complete your request. For more information, please visit the Settlement Website at xxx.XxxXxxxxXxxxXxxxxxxxxx.xxx, or call the Settlement Administrator at (XXX) XXX-XXXX. Questions? Go to xxx.XxxXxxxxXxxxXxxxxxxxxx.xxx or call (XXX) XXX-XXXX. *00000* *CF* *Page 4 of 4* 00000 CF Page 4 of 4
ATTESTATION & SIGNATURE. I swear and affirm under the laws of my state that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below. / / Signature Date Print name
ATTESTATION & SIGNATURE. I swear and affirm under the laws of the State of South Carolina that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below. / / Signature Date Printed Name *00000* *CF* *Page 5 of 5* 00000 CF Page 5 of 5 Xxxxxxx et al. x. Xxxxx St. Xxxxxxx Healthcare c/x Xxxxx Settlement Administration LLC P.O. Box [Number] New York, NY 10150-XXXX Electronic Service Requested FIRST-CLASS MAIL U.S. POSTAGE PAID CITY, ST PERMIT NO. XXXX
ATTESTATION & SIGNATURE. I swear and affirm that the information provided in this Claim Form, and any supporting documentation provided is true and correct to the best of my knowledge. I understand that my claim is subject to verification and that I may be asked to provide supplemental information by the Claims Administrator before my claim is considered complete and valid. EXHIBIT B (LONG FORM NOTICE)
