Claim Form - Thomas v. California Department of Corrections and Rehabilitation

1. CONTACT INFORMATION

If any of the following information changes, you must promptly notify us by emailing CDCRDataClassActionSettlement@cptgroup.com

First Name

Last Name

Address 1

Address 2

City

State or Territory

Zip

Type telephone number

Email Address

Confirm Email

CDCR_ID

Payment Method:

Please select the method by which you would like to receive the payment.

Please select only one:

I affirm under the laws of the State of California that the information supplied in this Claim Form is true and correct to the best of my knowledge. By signing and submitting this claim form, I assert under penalty of perjury that I reasonably believe I am a member of the class impacted by the breach.

I understand that I may be asked to provide more information by the Settlement Administrator before my claim is complete.

Date

(Type Name as Signature)

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