SIGN AND DATE YOUR CLAIM FORM. I declare under penalty of perjury and the laws of the United States and my state of residence that the information supplied in this Claim Form by the undersigned is true and correct to the best of my recollection, and that this form was executed on the date set forth below. / / Signature Print Name Month/Day/Year (mm/dd/yyyy)
SIGN AND DATE YOUR CLAIM FORM. I declare under penalty of perjury under the laws of the United States and the laws of my State of residence that the information supplied in this claim form by the undersigned is true and correct to the best of my recollection, and that this form was executed on the date set forth below. I understand that I may be asked to provide supplemental information by the Settlement Administrator before my claim will be considered complete and valid. Signature Print Name Date
SIGN AND DATE YOUR CLAIM FORM. I declare under penalty of perjury that the information supplied in this claim form is true and correct. I authorize the Settlement Administrator to contact me, using the contact information set forth above, to obtain any necessary supplemental information. Signature: Date (mm/dd/yyyy): Print Name: (__) The deadline to submit this form is [ ], 202_ Questions? Visit xxx.XXXXXXX.xxx or call Exhibit D UNITED STATES DISTRICT COURT NORTHERN DISTRICT OF ILLINOIS EASTERN DIVISION IN RE: MONDELEZ DATA BREACH LITIGATION This Document Relates To: All Actions Master File No.: 1:23-cv-03999 [PROPOSED] PRELIMINARY APPROVAL ORDER Before the Court is Plaintiffs’ Unopposed Motion for Preliminary Approval of Class Action Settlement (Doc. No. ) (the “Motion”), the terms of which are set forth in a Settlement Agreement and Release between Plaintiffs and Defendants Xxxxx Xxxx Xxxxxxxx Xxxxxxx LLP (“BCLP”) and Mondelēz Global LLC (“Mondelēz,” together with BCLP, collectively referred to as “Defendants”) (together with Plaintiffs, the “Parties”), with accompanying exhibits attached as Exhibit 1 to Plaintiffs’ Memorandum of Law in Support of their Motion (the “Settlement Agreement”).1 Having fully considered the issue, the Court hereby GRANTS the Motion and ORDERS as follows:
SIGN AND DATE YOUR CLAIM FORM. By signing below, I wish to claim any monies I may be owed under the Settlement. I have not assigned my rights to payment under this Settlement to anyone other than my mortgage lender (if any). The information in this Claim Form is true and correct to the best of my knowledge. Signature Print Name Date
SIGN AND DATE YOUR CLAIM FORM. I affirm that I wish to make a claim associated with the Settlement, and all of the information on this Claim Form is true and correct to the best of my knowledge. Signature Print Name Date
SIGN AND DATE YOUR CLAIM FORM. I certify under the laws of the United States and my state of residence that the information 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. I understand that I may be asked to provide supplemental information by the Claims Administrator before my claim will be considered complete and valid. / / Signature Print Name Month/Day/Year (mm/dd/yyyy)
SIGN AND DATE YOUR CLAIM FORM. I declare that the information supplied above is true and correct to the best of my recollection. I understand that I may be asked to provide supplemental information from the Settlement Administrator before my claim is considered complete and valid. Signature Printed Name Date
SIGN AND DATE YOUR CLAIM FORM. I declare that the information supplied above is true and correct to the best of my recollection. Signature Printed Name Date
SIGN AND DATE YOUR CLAIM FORM. I have read this Claim Form and declare under penalty of perjury that:
SIGN AND DATE YOUR CLAIM FORM. You must sign the Claim Form under penalty of perjury. Thus, make sure it is truthful. Claims will be verified. False claims will not be paid and people who submit false claims will be subject to prosecution. You also agree to promptly notify the Claims Administrator of the transfer of any interest in the Covered Property between the time that you submit this form and the time that any payment is made to you. If you inherited the Covered Property, you affirm that you also inherited your relative’s claims arising out of the Defendants’ installation, occupation, maintenance and use of Telecommunication Facilities on the Covered Property. I hereby certify under penalty of perjury that (1) the above and foregoing is true and correct; (2) I believe, in good faith, that I own or owned fee title to the Covered Property listed above; and (3) I will promptly notify the Claims Administrator of the transfer of any interest in the Covered Property between the time that I submit this form and the time that any payment is made to me. Class Member’s Signature Spouse’s Signature Print Name Print Name Date: Date:
