PART I – 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 First Name MI Beneficial Owner’s Last Name Co-Beneficial Owner’s First Name MI Co-Beneficial Owner’s Last Name Entity Name (if claimant is not an individual) Representative or Custodian Name (if different from Beneficial Owner(s) listed above) Address1 (street name and number) Address2 (apartment, unit, or box number) City State ZIP/Postal Code Foreign Country (only if not USA) Foreign County (only if not USA) Social Security Number Taxpayer Identification Number Telephone Number (home) Telephone Number (work) Email address Account Number (if filing for multiple accounts, file a separate Claim Form for each account) Claimant Account Type (check appropriate box): Individual (includes joint owner accounts) Pension Plan Trust Corporation Estate XXX/401K Other (please specify) PART II – SCHEDULE OF TRANSACTIONS IN XX. XXXXX’X ADSs
PART I – 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 Name Co-Beneficial Owner Name Address 1 (Street Name and Number) Xxxxxxx 0 (xxxxxxxxx, xxxx, xx box number) City State ZIP Foreign Province Foreign Country Telephone Number (home) Telephone Number (work) Email Address Account Number (if filing for multiple accounts, file a separate Claim Form for each account) Social Security Number (for individuals): OR Taxpayer Identification Number (for estates, trusts, corporations, etc.): Claimant Account Type (check appropriate box): Individual (includes joint owner accounts) Pension Plan Trust Corporation Estate IRA/401K Other (please specify) PART II – SCHEDULE OF TRANSACTIONS IN CHANGYOU ADSs
