Step 1 of 2 - Update Your Information 50% Unique ID Your claim must be submitted online or postmarked by:APRIL 30, 2024 STATE COURT OF GWINNETT COUNTY GEORGIA A.M. and A.M. v. Reproductive Associates LLC and MYEGGBANK North America LLC Case No. 21-C-06178-S3 Claim Form RBA/MEB Your claim must be submitted online or postmarked by:APRIL 30, 2024 STATE COURT OF GWINNETT COUNTY GEORGIA A.M. and A.M. v. Reproductive Associates LLC and MYEGGBANK North America LLC Case No. 21-C-06178-S3 Claim Form RBA/MEB GENERAL INSTRUCTIONS Settlement Class Members may submit a claim for cash payment. The total net settlement proceeds after payment of attorney fees, expenses, service awards, settlement administration costs, and costs associated with Notice will be distributed to Settlement Class Members who timely submit a valid claim on a pro rata basis. Questions? You may call the Settlement Administrator at: 1-888-998-6277. I. CLASS MEMBER NAME AND CONTACT INFORMATION You must notify the Settlement Administrator if your contact information changes after you submit this form. Claimant ID* Name* First Last Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Email Address* Telephone Number* II. CLAIM FOR DAMAGES Claim for damages* Check this box if you wish to make a claim for compensation of damages associated with the Data Incident. III. PAYMENT OPTIONS Settlement Class Members whose Claim Forms are determined to be timely and valid will receive their cash payments via an electronic payment method or by check. Please select the Payment Option by which you would like to receive your payment and complete the steps as prompted. Chosen Payment Method* HiddenPayment Token* IV. ATTESTATION & SIGNATURE Signature* I affirm that the information I have 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 all information provided on this Claim Form is subject to verification and that I may be asked to provide supplemental information by the Settlement Administrator before my claim will be considered complete and valid.
