Exhibit D Claims Forms
EXHIBIT 10.1D
EXHIBIT D: CLAIMS FORMS
Aqueous Film-Forming Foam (AFFF) Products Liability Litigation (MDL 2873) | |
INSTRUCTIONS | |
Please follow the instructions below to submit a claim for the AFFF Products Liability Litigation Settlement Program. A completed copy of this Claims Form must be submitted no later than the Claims Form Deadline. Late Claims Forms will not be considered. | |
SECTION 1. PUBLIC WATER SYSTEM (PWS) INFORMATION | |
SECTION 1.1 PWS GENERAL INFORMATION | |
Public Water System (PWS) Name |
Exhibit D Page 1
EXHIBIT 10.1D
PWS Identification Number (PWSID) | Employer Identification Number | ___ ___ - ___ ___ ___ ___ ___ ___ ___ | ||
PWS Facility Address | Street | |||
City | State | Zip | ||
SECTION 1.2 PWS CONTACT INFORMATION | ||||
Name of PWS Primary Contact | Job Title of PWS Primary Contact | |||
Telephone Number for Primary Contact |
| Fax Number |
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Email Address for Primary Contact | PWS "General" Email (if available) | |||
Name of PWS Secondary Contact | Job Title of PWS Secondary Contact | |||
Telephone Number for Secondary Contact |
| Email Address for Secondary Contact | ||
*Payments will be sent to this address | Street/PO Box | |||
City | State | Zip |
Exhibit D Page 2
EXHIBIT 10.1D
SECTION 1.3 LAWSUIT INFORMATION (CHECK YES OR NO) | YES | NO | ||
Has PWS filed a lawsuit to recover damages associated with PFAS contamination of its public drinking water wells or surface water systems? | ||||
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If the lawsuit is NOT currently in the AFFF MDL, in which court is it pending? | ||||
Case Number | ||||
SECTION 1.4 ATTORNEY INFORMATION (IF APPLICABLE) | YES | NO | ||
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Attorney Name | Law Firm Name | |||
Telephone Number | (________) ________ - ____________ | Email Address | ||
Law Firm Employer Identification Number | ||||
SECTION 2. QUALIFYING PWS INFORMATION | ||||
QUALIFYING QUESTIONS (CHECK YES OR NO) | YES | NO | ||
Is the PWS required to test under UCMR-5? | ||||
Is the PWS required to test for PFAS by state law? | ||||
Does the PWS serve at least 15 service connections used by year-round residents? |
Exhibit D Page 3
EXHIBIT 10.1D
Does the PWS serve at least 25 year-round residents? | ||
Does the PWS serve fewer than 3,300 according to SDWIS as of {Settlement Date}? | ||
Is the PWS in the United States of America or one of its territories? | ||
Is the PWS owned or operated by a state (or territory of the United States) or the federal government? | ||
PWS CODES WITHIN THE SAFE DRINKING WATER INFORMATION SYSTEM (SDWIS) | ||
What is the PWS Owner Type Code as listed in SDWIS? | ||
If the PWS Owner Type Code is listed in SDWIS as either "S-State Government" or "F-Federal Government," does the PWS have the authority to sue or be sued in its own name? | ||
*Please enter one of the following: “Active”, “Inactive”, “Change from public to non-public”, “Merged with another system” or “Potential future system to be regulated” | ||
What is the PWS classification as listed in SDWIS? |
Exhibit D Page 4
EXHIBIT 10.1D
SECTION 3. WATER SOURCE SUMMARY INFORMATION | ||
GROUNDWATER WELL SUMMARY | QUANTITY | |
How many Groundwater Wells are owned or operated by the PWS? | ||
How many of these Groundwater Wells have been analyzed using a state or federal agency-approved analytical method consistent with the requirements of UCMR 5 (or stricter) and show a measurable concentration of PFAS prior to {Settlement Date}? | ||
How many of these Groundwater Wells have been analyzed using a state or federal agency-approved analytical method consistent with the requirements of UCMR 5 (or stricter) and DO NOT show a measurable concentration of PFAS since U.S. EPA’s announcement of the testing requirements of UCMR 5? | ||
SURFACE WATER SYSTEM SUMMARY | QUANTITY | |
How many Surface Water Systems are owned or operated by the PWS? | ||
How many of these Surface Water Systems have been analyzed using a state or federal agency approved analytical method consistent with the requirements of UCMR 5 (or stricter) and show a measurable concentration of PFAS prior to {Settlement Date}? | ||
How many of these Surface Water Systems have been analyzed using a state or federal agency approved analytical method consistent with the requirements of UCMR 5 (or stricter ) and DO NOT show a measurable concentration of PFAS since U.S. EPA’s announcement of the testing requirements of UCMR 5? | ||
SECTION 4. WATER SOURCE INFORMATION | ||
Please complete and submit information from Section 4 for EACH Water Source. See "Addendum X" to provide information for each additional Water Source. | ||
Name or description of the Water Source. |
Exhibit D Page 5
EXHIBIT 10.1D
Is this a Groundwater Well or Surface Water System? | |||
WATER SOURCE QUESTIONS (CHECK YES OR NO) | YES | NO | |
Does the PWS own this Water Source? | |||
Does the PWS operate this Water Source? | |||
Has the water from this Water Source ever been used as drinking water? | |||
Was this Water Source tested or otherwise analyzed for PFAS using a state or federal agency approved analytical method consistent with the requirements of UCMR 5 (or stricter) and found to contain any measurable concentration of PFAS on or before the {Settlement Date}? | |||
Was this Water Source tested or otherwise analyzed for PFAS after U.S. EPA’s announcement of the testing requirements of UCMR 5 using a state or federal agency approved analytical method consistent with the requirements of UCMR 5 (or stricter) and found NOT to contain any PFAS at any level?
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FLOW RATE / CAPACITY | |||
Please answer the below questions indicating the maximum flow rate / capacity for the water source. Please indicate (check the correct box) if the measurement is in gallons per minute (GPM) or million gallons per day (MGD). | |||
FLOW RATE / CAPACITY QUESTIONS | MAX FLOW RATE / CAPACITY | GPM | MGD |
If this Water Source is a Groundwater Well, please enter the maximum flow rate. |
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Exhibit D Page 6
EXHIBIT 10.1D
If this Water Source is a Surface Water System, please enter the maximum capacity of the treatment system. |
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How was the maximum flow rate or capacity determined? | ||||
Note: Please indicate if the measurement is in gallons per minute (GPM) or million gallons per day (MGD) by checking the corresponding box. If the source was not in a particular year, please enter "0" (zero) for the Average Annual Flow Rate. | ||||
YEAR | AVERAGE ANNUAL FLOW RATE | GPM | MGD | Was the Avg. Annual Flow Rate reduced due to PFAS Contamination? |
Groundwater Well Example: 2013 | 1500 | |
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Surface Water System Example: 2014 | 4.3 |
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2013 |
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2014 |
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2015 |
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2016 |
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2017 |
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2018 |
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Exhibit D Page 7
EXHIBIT 10.1D
2019 |
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2020 |
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2021 |
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2022 |
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ADDITIONAL FLOW RATE INFORMATION (IF NECESSARY) | ||||
Each PWS is required to provide data for at least 3 years for which the Average Annual Flow Rate (AAFR) was not reduced due to PFAS contamination if available. If the PWS did not provide data for at least 3 years in which the AAFR was not reduced due to PFAS contamination (in the table above), please use the space below to provide additional information as needed. For example, if the AAFR for 9 of the previous 10 years has been reduced due to PFAS contamination, the PWS should provide 2 years of data below for the most recent unimpacted years. | ||||
YEAR | AVERAGE ANNUAL FLOW RATE | GPM | MGD | |
EXAMPLE: 2009 | 3000 | |
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EXAMPLE: 2010 | 3500 | |
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Exhibit D Page 8
EXHIBIT 10.1D
SECTION 5. PFAS TESTING RESULTS | |||
PFOA CONTAMINATION TESTING | |||
Please enter the below information to indicate PFOA contamination testing results. If this water source was not found to contain any PFAS at any level in testing under the Testing Methodology (as defined above) after U.S. EPA’s announcement of the testing requirements of UCMR 5, leave this section blank and skip to Section 6: Certification and Signature. | |||
Highest historical PFOA concentration in lab issued documentation: | |||
Date of Sampling: | |||
Company of the person who took the sample: | |||
Date of analysis: | |||
Highest historical PFOA concentration converted to parts per trillion (PPT): |
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Name of laboratory that performed the analysis: | |||
Facility address of laboratory that performed the analysis: | Street/PO Box | ||
City | State | Zip | |
What state or federal agency approved analytical method was used to measure the PFAS concentrations on the Impacted Water Source (e.g., EPA Method 537.1)? |
Exhibit D Page 9
EXHIBIT 10.1D
PFOS CONTAMINATION TESTING | |||
Please enter the below information to indicate PFOS contamination testing results. If this water source was not found to contain any PFAS at any level in testing under the Testing Methodology (as defined above) after U.S. EPA’s announcement of the testing requirements of UCMR 5, leave this section blank and skip to Section 6: Certification and Signature. | |||
Highest historical PFOS concentration in lab issued documentation: | |||
Date of Sampling: | |||
Company of the person who took the sample: | |||
Date of analysis: | |||
Highest historical PFOS concentration converted to parts per trillion (PPT): |
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Name of laboratory that performed the analysis: | |||
Facility address of laboratory that performed the analysis: | Street/PO Box | ||
City | State | Zip | |
What state or federal agency approved analytical method was used to measure the PFAS concentrations on the Impacted Water Source (e.g., EPA Method 537.1)? |
Exhibit D Page 10
EXHIBIT 10.1D
OTHER PFAS CONTAMINATION TESTING | |||
Please enter the below information to indicate other PFAS Chemical contamination testing results. If this water source was not found to contain any PFAS at any level in testing under the Testing Methodology (as defined above) after U.S. EPA’s announcement of the testing requirements of UCMR 5, leave this section blank and skip to Section 6: Certification and Signature. | |||
Highest historical concentration of one other PFAS Chemical in lab issued documentation: | |||
Date of Sampling: | |||
Company of the person who took the sample: | |||
Date of analysis: | |||
Highest historical concentration of one other PFAS Chemical concentration converted to parts per trillion (PPT): |
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Name of laboratory that performed the analysis: | |||
Facility address of laboratory that performed the analysis: | Street/PO Box | ||
City | State | Zip | |
What state or federal agency approved analytical method was used to measure the PFAS concentrations on the Impacted Water Source (e.g., EPA Method 537.1)? |
Exhibit D Page 11
EXHIBIT 10.1D
SECTION 6. CERTIFICATION AND SIGNATURE | |
By signing this Claims Form, Settlement Class Member represents and warrants the following for the benefit of Settling Defendants: | |
I hereby declare under penalty of perjury under the laws of the State of __________________________________________ that the information within this Claims Form and its attachments are true and correct to the best of my knowledge, information, and belief. | |
Authorized Representative's Signature: | |
Authorized Representative's Printed Name: | |
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DOCUMENTATION REQUIREMENTS | |
Please submit ALL documentation reflecting the information provided above including the following: |
Exhibit D Page 12
EXHIBIT 10.1D
6. A duly completed written statement that satisfies the requirements of Treasury Regulations Section 1.6050X-1(c) with respect to each Settling Defendant 7. A written authorization substantially in the form of Exhibit K attached to the Settlement Agreement for the Claims Administrator to file the forms set forth in item (5) with the IRS and to provide the written statements set forth in item (6) to each Settling Defendant |
Exhibit D Page 13
EXHIBIT 10.1D
Aqueous Film-Forming Foam (AFFF) Products Liability Litigation (MDL 2873) |
INSTRUCTIONS |
Please follow the instructions below to submit a Supplemental claim for the AFFF Products Liability Litigation Settlement Program. A completed copy of this Claims Form must be submitted no later than the {Supplemental Claims Form Deadline}. Late Claims Forms will not be considered. |
Exhibit D Page 14
EXHIBIT 10.1D
SECTION 1. PUBLIC WATER SYSTEM (PWS) INFORMATION | |||
SECTION 1.1 PWS GENERAL INFORMATION | |||
Public Water System (PWS) Name | |||
PWS Identification Number (PWSID) | Employer Identification Number | ___ ___ - ___ ___ ___ ___ ___ ___ ___ | |
SECTION 2. WATER SOURCE INFORMATION | |||
Please complete and submit information from Section 4 for EACH Water Source. See "Addendum X" to provide information for each additional Water Source. | |||
Name or description of the Water Source. | |||
Is this a Groundwater Well or Surface Water System? | |||
SECTION 3. PFAS TESTING RESULTS | |||
PFOA CONTAMINATION TESTING | |||
Please enter the below information to indicate PFOA contamination testing results. If this water source was not found to contain any PFAS at any level on or before the {Settlement Date}, leave this section blank and skip to Section 6: Certification and Signature. | |||
Highest historical PFOA concentration in lab issued documentation: |
Exhibit D Page 15
EXHIBIT 10.1D
Date of Sampling: | |||
Company of the person who took the sample: | |||
Date of analysis: | |||
Highest historical PFOA concentration converted to parts per trillion (PPT): |
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Name of laboratory that performed the analysis: | |||
Facility address of laboratory that performed the analysis: | Street/PO Box | ||
City | State | Zip | |
What state or federal agency approved analytical method was used to measure the PFAS concentrations on the Impacted Water Source (e.g., EPA Method 537.1)? | |||
PFOS CONTAMINATION TESTING | |||
Please enter the below information to indicate PFOS contamination testing results. If this water source was not found to contain any PFAS at any level in testing under the Testing Methodology (as defined above) after U.S. EPA’s announcement of the testing requirements of UCMR 5, leave this section blank and skip to Section 6: Certification and Signature. | |||
Highest historical PFOS concentration in lab issued documentation: | |||
Date of Sampling: |
Exhibit D Page 16
EXHIBIT 10.1D
Company of the person who took the sample: | |||
Date of analysis: | |||
Highest historical PFOS concentration converted to parts per trillion (PPT): |
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Name of laboratory that performed the analysis: | |||
Facility address of laboratory that performed the analysis: | Street/PO Box | ||
City | State | Zip | |
What state or federal agency approved analytical method was used to measure the PFAS concentrations on the Impacted Water Source (e.g., EPA Method 537.1)? | |||
OTHER PFAS CONTAMINATION TESTING | |||
Please enter the below information to indicate other PFAS Chemical contamination testing results. If this water source was not found to contain any PFAS at any level in testing under the Testing Methodology (as defined above) after U.S. EPA’s announcement of the testing requirements of UCMR 5, leave this section blank and skip to Section 6: Certification and Signature. | |||
Highest historical concentration of one other PFAS Chemical in lab issued documentation: | |||
Date of Sampling: | |||
Company of the person who took the sample: |
Exhibit D Page 17
EXHIBIT 10.1D
Date of analysis: | ||||
Highest historical concentration of one other PFAS Chemical concentration converted to parts per trillion (PPT): |
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Name of laboratory that performed the analysis: | ||||
Facility address of laboratory that performed the analysis: | Street/PO Box | |||
City | State | Zip | ||
What state or federal agency approved analytical method was used to measure the PFAS concentrations on the Impacted Water Source (e.g., EPA Method 537.1)? | ||||
SECTION 4. CERTIFICATION AND SIGNATURE | ||||
By signing this Claims Form, Settlement Class Member represents and warrants the following for the benefit of Settling Defendants: | ||||
I hereby declare under penalty of perjury under the laws of the State of __________________________________________ that the information within this Claims Form and its attachments are true and correct to the best of my knowledge, information, and belief. | ||||
Authorized Representative's Signature: |
Exhibit D Page 18
EXHIBIT 10.1D
Authorized Representative's Printed Name: | |
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DOCUMENTATION REQUIREMENTS | |
Please submit ALL documentation reflecting the information provided above including the following: 3. A duly completed and executed IRS Form W-9 (or other information return required pursuant to Treasury Regulations Section 1.6050X-1(a)(1)) for the PWS with respect to each Settling Defendant, 4. A duly completed written statement that satisfies the requirements of Treasury Regulations Section 1.6050X-1(c) with respect to each Settling Defendant 5. A written authorization substantially in the form of Exhibit K attached to the Settlement Agreement for the Claims Administrator to file the forms set forth in item (3) with the IRS and to provide the written statements set forth in item (6) to each Settling Defendant |
Exhibit D Page 19
EXHIBIT 10.1D
Aqueous Film-Forming Foam (AFFF) Products Liability Litigation (MDL 2873) | |||
INSTRUCTIONS | |||
Please follow the instructions below to submit a Special Needs claim for the AFFF Products Liability Litigation Settlement Program. A completed copy of this Claims Form must be submitted no later than the {Special Needs Claims Form Deadline}. Late Claims Forms will not be considered. | |||
SECTION 1. PUBLIC WATER SYSTEM (PWS) INFORMATION | |||
Public Water System (PWS) Name | |||
PWS Identification Number (PWSID) | Employer Identification Number | ___ ___ - ___ ___ ___ ___ ___ ___ ___ |
Exhibit D Page 20
EXHIBIT 10.1D
SECTION 2. SPECIAL NEEDS CLAIM INFORMATION | |
NARRATIVE OF NEED/ISSUE | |
Total Amount Claimed | $ __________________________________ . ____ ____ |
Exhibit D Page 21
EXHIBIT 10.1D
SECTION 3. CERTIFICATION AND SIGNATURE | |
By signing this Claims Form, Settlement Class Member represents and warrants the following for the benefit of Settling Defendants: | |
I hereby declare under penalty of perjury under the laws of the State of __________________________________________ that the information within this Claims Form and its attachments are true and correct to the best of my knowledge, information, and belief. | |
Authorized Representative's Signature: | |
Authorized Representative's Printed Name: | |
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DOCUMENTATION REQUIREMENTS | |
1. A duly completed and executed IRS Form W-9 (or other information return required pursuant to Treasury Regulations Section 1.6050X-1(a)(1)) for the PWS with respect to each Settling Defendant, 2. A duly completed written statement that satisfies the requirements of Treasury Regulations Section 1.6050X-1(c) with respect to each Settling Defendant 3. A written authorization substantially in the form of Exhibit K attached to the Settlement Agreement for the Claims Administrator to file the forms set forth in item (1) with the IRS and to provide the written statements set forth in item (6) to each Settling Defendant |
Exhibit D Page 22
EXHIBIT 10.1D
Aqueous Film-Forming Foam (AFFF) Products Liability Litigation (MDL 2873) | |||
INSTRUCTIONS | |||
Please follow the instructions below to submit a Testing Compensation claim for the AFFF Products Liability Litigation Settlement Program. A completed copy of this Claims Form must be submitted no later than the {Testing Compensation Claims Form Deadline}. Late Claims Forms will not be considered. | |||
SECTION 1. PUBLIC WATER SYSTEM (PWS) INFORMATION | |||
SECTION 1.1 PWS GENERAL INFORMATION | |||
Public Water System (PWS) Name | |||
PWS Identification Number (PWSID) | Employer Identification Number | ___ ___ - ___ ___ ___ ___ ___ ___ ___ |
Exhibit D Page 23
EXHIBIT 10.1D
PWS Facility Address | Street | |||
City | State | Zip | ||
SECTION 1.2 PWS CONTACT INFORMATION | ||||
Name of PWS Primary Contact | Job Title of PWS Primary Contact | |||
Telephone Number for Primary Contact |
| Fax Number |
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Email Address for Primary Contact | PWS "General" Email (if available) | |||
Name of PWS Secondary Contact | Job Title of PWS Secondary Contact | |||
Telephone Number for Secondary Contact |
| Email Address for Secondary Contact | ||
PWS Mailing Address | Street/PO Box | |||
City | State | Zip | ||
SECTION 1.3 LAWSUIT INFORMATION (CHECK YES OR NO) | YES | NO | ||
Has PWS filed a lawsuit to recover damages associated with PFAS contamination of its public drinking water wells or surface water systems? |
Exhibit D Page 24
EXHIBIT 10.1D
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If the lawsuit is NOT currently in the AFFF MDL, in which court is it pending? | ||||
Case Number | ||||
SECTION 1.4 ATTORNEY INFORMATION (IF APPLICABLE) | YES | NO | ||
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Attorney Name | Law Firm Name | |||
Telephone Number | (________) ________ - ____________ | Email Address | ||
Law Firm Employer Identification Number | ||||
SECTION 2. QUALIFYING PWS INFORMATION | ||||
QUALIFYING QUESTIONS (CHECK YES OR NO) | YES | NO | ||
Is the PWS required to test under UCMR-5? | ||||
Is the PWS required to test for PFAS by state law? | ||||
Does the PWS serve at least 15 service connections used by year-round residents? | ||||
Does the PWS serve at least 25 year-round residents? | ||||
Does the PWS fewer than 3,300 peopleaccording to SDWIS as of {Settlement Date}? |
Exhibit D Page 25
EXHIBIT 10.1D
Is the PWS in the United States of America or one of its territories? | ||
Is the PWS owned or operated by a state (or territory of the United States) or the federal government? | ||
PWS CODES WITHIN THE SAFE DRINKING WATER INFORMATION SYSTEM (SDWIS) | ||
What is the PWS Owner Type Code as listed in SDWIS? | ||
If the PWS Owner Type Code is listed in SDWIS as either "S-State Government" or "F-Federal Government," does the PWS have the authority to sue or be sued in its own name? | ||
*Please enter one of the following: “Active”, “Inactive”, “Change from public to non-public”, “Merged with another system” or “Potential future system to be regulated” | ||
What is the PWS classification as listed in SDWIS? | ||
SECTION 3. WATER SOURCE SUMMARY INFORMATION | ||
How many Groundwater Wells are owned or operated by the PWS? | ||
How many Surface Water Systems are owned or operated by the PWS? |
Exhibit D Page 26
EXHIBIT 10.1D
SECTION 4. CERTIFICATION AND SIGNATURE | |
By signing this Claims Form, Settlement Class Member represents and warrants the following for the benefit of Settling Defendants: | |
I hereby declare under penalty of perjury under the laws of the State of __________________________________________ that the information within this Claims Form and its attachments are true and correct to the best of my knowledge, information, and belief. | |
Authorized Representative's Signature: | |
Authorized Representative's Printed Name: | |
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DOCUMENTATION REQUIREMENTS | |
1. A duly completed and executed IRS Form W-9 (or other information return required pursuant to Treasury Regulations Section 1.6050X-1(a)(1)) for the PWS with respect to each Settling Defendant, 2. A duly completed written statement that satisfies the requirements of Treasury Regulations Section 1.6050X-1(c) with respect to each Settling Defendant 3. A written authorization substantially in the form of Exhibit K attached to the Settlement Agreement for the Claims Administrator to file the forms set forth in item (1) with the IRS and to provide the written statements set forth in item (6) to each Settling Defendant |
Exhibit D Page 27