Sign and Date Your Claim Form Sample Clauses

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
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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. I understand that I may be asked to provide supplemental information by the Claims Administrator or Claims Referee before my claim will be considered complete and valid. / / Signature Print Name Month/Day/Year (mm/dd/yyyy)
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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
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Sign and Date Your Claim Form. I have read this Claim Form and declare under penalty of perjury that:
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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:
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Sign and Date Your Claim Form. Your Claim Form must be signed. Eligibility for benefits under the Settlement is subject to the terms and conditions contained in the governing Settlement Agreement. See the Settlement Agreement and detailed notice of the proposed Settlement, available at xxx.xxxxxxx.xxx, or call 0-000-XXX-XXXX for more information. Benefits will be provided after Final Approval of the Settlement and after all claims are processed. Please be patient. I affirm, under penalty of perjury, that: (1) I am a Current Subscriber of Cablevision’s cable TV service and (2) to the best of my recollection, the information provided in this Claim Form is true and correct. Print Name Signature Date (MM/DD/YY) Exhibit B FORMER CABLEVISION SUBSCRIBERS CLAIM FORM To receive a payment or other benefit, you must accurately complete this Claim Form and submit it no later than Month XX, 0000. Claim Forms may be submitted online at xxx.xxxxxx.xxx or by mail to: [ADDRESS]. Claims must be submitted online or postmarked by Month XX, 0000. Authorized claimants may receive a payment between $20-40 depending on the length of time that they were Cablevision cable TV subscribers. In addition to a payment, authorized claimants will also receive access to a free four month subscription to the Internet-delivered SundanceNow service from AMC. Information on how to obtain SundanceNow will be provided following Final Approval of the Settlement by the Court.
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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
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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
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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
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Related to Sign and Date Your Claim Form

  • Required Confidentiality Claim Form This is a requirement of the TIPS Contract and is non-negotiable. TIPS provides the required TIPS Confidentiality Claim Form in the "Attachments" section of this solicitation. Vendor must execute this form by either signing and waiving any confidentiality claim, or designating portions of Vendor's proposal confidential. If Vendor considers any portion of Vendor's proposal to be confidential and not subject to public disclosure pursuant to Chapter 552 Texas Gov’t Code or other law(s) and orders, Vendor must have identified the claimed confidential materials through proper execution of the Confidentiality Claim Form. If TIPS receives a public information act or similar request, any responsive documentation not deemed confidential by you in this manner will be automatically released. For Vendor documents deemed confidential by you in this manner, TIPS will follow procedures of controlling statute(s) regarding any claim of confidentiality and shall not be liable for any release of information required by law, including Attorney General determination and opinion. Notwithstanding any other Vendor designation of Vendor's proposal as confidential or proprietary, Vendor’s submission of this proposal constitutes Vendor’s agreement that proper execution of the required TIPS Confidentiality Claim Form is the only way to assert any portion of Vendor's proposal as confidential.

  • Data Protection Impact Assessment and Prior Consultation Processor shall provide reasonable assistance to the Company with any data protection impact assessments, and prior consultations with Supervising Authorities or other competent data privacy authorities, which Company reasonably considers to be required by article 35 or 36 of the GDPR or equivalent provisions of any other Data Protection Law, in each case solely in relation to Processing of Company Personal Data by, and taking into account the nature of the Processing and information available to, the Contracted Processors.

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