Contact Information

Please Note: The Settlement Administrator will use this information for all communications regarding this Claim Form. If the information changes, you MUST notify the Settlement Administrator at the address listed on the Contact page.

Please select which type of Claimant you are:*

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Co-Beneficial Owner's Name (If applicable, provide all information)

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Beneficial Owner's Social Security Number (Last 4):*

Note: If you do not have a Social Security number, enter "9999".

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Taxpayer Identification Number (Last 4):*

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