By signing and dating this form below, I acknowledge that I have read the terms and conditions herein and am qualified to seek compensation under this settlement. I further attest that I have not submitted, and will not in the future submit, any other Claim Form seeking compensation from this settlement.
I understand that my Claim and the information provided will be subject to verification. By submitting this Claim Form, I affirm under penalty of perjury that the information it contains is accurate.