CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Claimant Names(s) (as the name(s) should appear on check, if eligible for payment; if the shares are jointly owned, the names of all beneficial owners must be provided): Name of Person the Claims Administrator Should Contact Regarding this Claim Form (Must Be Provided): Mailing Address – Line 1: Street Address/P.O. Box: Mailing Address – Line 2 (If Applicable): Apartment/Suite/Floor Number: City: State/Province: Zip Code: Country: Last 4 digits of Claimant Social Security/Taxpayer Identification Number:1
CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST notify the Claims Administrator in writing at the address above. Complete names of all persons and entities must be provided. Beneficial Owner’s Name First Name Last Name Joint Beneficial Owner’s Name (if applicable) First Name Last Name If this claim is submitted for an XXX, and if you would like any check that you MAY be eligible to receive made payable to the XXX, please include “XXX” in the “Last Name” box above (e.g., Xxxxx XXX). Entity Name (if the Beneficial Owner is not an individual) Name of Representative, if applicable (executor, administrator, trustee, c/o, etc.), if different from Beneficial Owner Last 4 digits of Social Security Number or Taxpayer Identification Number Street Address City State/Province Zip Code Foreign Postal Code (if applicable) Foreign Country (if applicable) Telephone Number (Day) Telephone Number (Evening) Email Address (email address is not required, but if you provide it you authorize the Claims Administrator to use it in providing you with information relevant to this claim): Specify one of the following: Individual(s) Corporation UGMA Custodian XXX Partnership
CLAIMANT INFORMATION. The Settlement Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes prior to distribution of cash payments, you must notify the Settlement Administrator in writing at the address above. Claimant Name: Street Address: ___________________________________ ____________________________________ First Name MI Last Name Street Address Second Line: City: State: Zip Code: Class Member ID: If you received a notice of this Settlement by U.S. mail, your Class Member ID is on the envelope or postcard. If you received a notice of this Settlement by email, your Class Member ID is in the email. E-mail Address: [optional] Daytime Phone Number: ( _ _ _ ) _ _ _ - _ _ _ [optional] Evening Phone Number: ( _ _ ) _ _ - _ _ _
CLAIMANT INFORMATION. Provide your contact information below. It is your responsibility to notify the Settlement Admininstrator of any changes to your contact information.
CLAIMANT INFORMATION. The Claims Administrator will use this information for all communications regarding this claim (including the check, if eligible for payment). If this information changes, you MUST notify the Claims Administrator in writing at the address above. Claimant Name(s): Street Address: City: State: Zip Code: Country: Last four digits of Social Security Number or Taxpayer Identification Number:
CLAIMANT INFORMATION. The amount of any individual payment or Award made to an Enrolled Claimant under this Agreement (such amount information, “Award Information”), shall be kept confidential by Bayer, the Claims Administrator and the QSF Administrator and shall not be disclosed except (i) to appropriate Persons to the extent necessary to process Program Claims or provide benefits under this Agreement, (ii) as otherwise expressly provided in this Agreement, (iii) as may be required by law, lawful compulsory order or listing agreements, (iv) as may be reasonably necessary in order to enforce, or exercise Bayer’s rights under, or with respect to, such Enrolled Claimant’s Claims Form(s), Release(s), Stipulation(s) of Dismissal or (with respect to such Enrolled Claimant or his Counsel, as applicable) this Agreement or (v) in any action brought by Bayer for contribution against any Additional Released Party, provided that such Award Information shall be protected by the highest level of confidentiality available under the protective order in such case. All Enrolled Claimants shall be deemed to have consented to the disclosure of the Award Information for these purposes.
CLAIMANT INFORMATION. You must provide your name and current contact information below. It is your responsibility to tell the Settlement Administrator if your contact information changes after you submit this form. FIRST NAME LAST NAME STREET ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER EMAIL ADDRESS
CLAIMANT INFORMATION. Your Full Name: Any other names you have had or used at any time since January 1, 2011: Street Address: Telephone: Email address: Last 4 Digits of Social Security Number:
1. Are you African American? Yes О No О
CLAIMANT INFORMATION. Your Full Name: Any other names you have had or used at any time since January 1, 2011: Street Address: Telephone: Email address: Last 4 Digits of Social Security Number:
1. Are you African American? Yes О No О
2. Did you fail the Criminal Background Policy? Yes О No О
3. After failing, were you denied employment, terminated, or suspended by WMATA or a WMATA contractor? Yes О No О
4. Have you declared bankruptcy? Yes О No О If yes, please fill our Section G on the following page.
CLAIMANT INFORMATION. (Please read General Instructions above before completing this page.)
