Current Telephone Number. B. Provide the following information about the Deceased Class Member to whom this Heirship Form pertains:
Current Telephone Number. ( ) - - Cellphone Number(s) at Which You Received the Text Message(s): ( ) - - ( ) - - Class Member ID (if known): TO RECEIVE BENEFITS FROM THIS SETTLEMENT, YOU MUST PROVIDE ALL OF THE INFORMATION ABOVE, AND YOU MUST SIGN THIS CLAIM FORM. YOUR CLAIM FORM MUST BE SUBMITTED ONLINE BY 11:59 P.M. CENTRAL TIME ON [CLAIMS DEADLINE] OR SENT BY MAIL TO THE ADDRESS BELOW AND POSTMARKED BY [CLAIMS DEADLINE] Xxxxxxxxx Xxxxx v. Bluestem Brands, Inc. Bluestem Brands Text Settlement Claims Administrator [Address] Class Member Affirmation: By submitting this Claim Form and checking the box below, I declare that I am a member of the Settlement Class and that the following statement is true (box must be checked to receive payment): I affirm that I was the subscriber or primary user of the cellular telephone number(s) listed above at some time from March 14, 2012, through October 15, 2018, that I received one or more text messages from Bluestem at the number(s) identified above and that I did not have an account with a Bluestem business (Fingerhut or Gettington) or otherwise did not consent to receive those text messages. I declare under penalty of perjury under the laws of the State in which this affirmation is executed and the United States of America that the information provided above is true and correct. SIGNATURE: PRINTED NAME: DATED: / / [admin] ID: «[Admin] ID» «First Name» «Last Name» «Address1» «City», «State» «Zip» Carefully separate at perforation UNITED STATES DISTRICT COURT DISTRICT OF MINNESOTA Xxxxxxxxx Xxxxx v. Bluestem Brands, Inc., Case No. 16-cv-00644-WMW-HB (D. Minn.) CLAIM FORM Name/Address Changes: I am a member of the settlement class in Xxxxx v. Bluestem. I affirm that I was the subscriber or primary user of the cellular telephone number(s) listed below at some time from March 14, 2012, through October 15, 2018, that I received one or more text messages from Bluestem at the number and that I did not have an account with a Bluestem business (Fingerhut or Gettington) or otherwise did not consent to receive those text messages. I declare under penalty of perjury under the laws of the State in which this affirmation is executed and the U.S. that the information provided above is true and correct. Signature: Telephone number on which I received the text(s): Date of signature: To receive a payment you must enter all requested information above, sign and mail this claim form, postmarked on or before [Month] [day], 2019. Or you may visit the settlement webs...
Current Telephone Number. Cell Phone Number Email Address: Email Address: Have you ever owned a home? If so, when? Have you ever owned a home? If so, when? Where was the house located? Where/was the house located? Why did you move? Why did you move? EMPLOYMENT INFORMATION EMPLOYER: EMPLOYER: Work Address Work Phone # Start Date Work Address Work Phone# Start Date Job Title How Long in this position? Job Title How Long in this position? TYPE OF BUSINESS: WORK PHONE: TYPE OF BUSINESS: WORK PHONE: Type of Benefits in current Employment □ Health □Retirement □ Other Type of Benefits in current Employment □ Health □Retirement □ Other Monthly Income: #Hrs /wk Monthly Income: #Hrs/wk Monthly Income Information Applicant Base Employment: $ Co-Applicant $ Overtime Income: $ $ Commissions $ $ Dividends/Interest $ $ Child Support Income $ $ Disability Income $ $ Other (Please Describe) $ $ Assets and Liabilities List Savings & Checking Accounts: X NAME OF BANK STREET ADDRESS CITY STATE ZIP HEAD OF HOUSEHOLD: Account Number(s): □ Savings □ Checking Balance X NAME OF BANK STREET ADDRESS CITY STATE ZIP APPLICANT: ACCOUNT NUMBER(S): □ SAVINGS □CHECKING BALANCE $ X NAME OF BANK STREET ADDRESS CITY STATE ZIP CO-APPLICANT: ACCOUNT NUMBER(S) □ SAVINGS □ CHECKING BALANCE $ _ X Name of Bank Street Address City State Zip CO-APPLICANT: ACCOUNT NUMBER(S) _ □SAVINGS □ CHECKING BALANCE $ List all other creditors: Provide names, address, account number and balance. Include charge accounts, alimony, child support, student loans, and any other outstanding debts. Name & Address of Company Account No. MONTHLY PAYMENTS $ UNPAID BALANCE $ Name & Address of Company Account No. MONTHLY PAYMENTS $ UNPAID BALANCE $ DO YOU HAVE STUDENT LOANS THAT NEED TO BE REPAID □ YES □ NO IF YES, WHAT IS THE BALANCE DUE? $ MONTHLY PAYMENTS? _ IS/ARE STUDENT LOANS CURRENTLY IN DEFERMENT? DEFERMENT ENDS? Information About You and Your Family How many adults are in your household? How many children are in your household? Do you have legal custody of these children? List the names, ages and sex of all other members of your household not listed as Head or Co-Head of Household: NAME: AGE: MALE OR FEMALE (CIRCLE) NAME: AGE: MALE OR FEMALE (CIRCLE) NAME: AGE: MALE OR FEMALE (CIRCLE) NAME: AGE: MALE OR FEMALE (CIRCLE) Racial/Ethnic Classification: Providing this information is strictly voluntary. NOTE: If you elect not to answer, it will not affect your eligibility for the Homeownership Made Easy Program White, not of Hispanic Origin Black, n...
