The Claims Administrator will use this information for all communications regarding this Claim Form. If this information changes, you MUST
notify the Claims Administrator in writing at the address above.
*By providing your email address, you authorize the Claims Administrator to use it in providing you with information relevant to this claim.
Are you an Agent or Legal Representative Submitting this Form on Behalf of the Settlement Class Member?
By providing your e-mail address, you authorize the Claims Administrator to use it in providing you with information relevant to this claim.
Provide the amount of money you spent on each drug for prescriptions filled before August 1, 2019 for use by you or your family. Only include
purchases made in California, the District of Columbia, Florida, Kansas, Maine, Massachusetts, Michigan, Nebraska, New York, North Carolina,
Oregon, Pennsylvania, Rhode Island, or Tennessee. In other words, you had to reside in, submit a payment in, or your pharmacy had to be located in one of these states
when you paid for the drugs.
You do not need to provide any documentation at this time. However, the Claims Administrator may ask for additional proof of purchase.
I have read and am familiar with the contents of this Claim Form. I certify that the information provided by me is true, correct and
complete to the best of my knowledge. I further certify that I am submitting this information on behalf of myself or a Settlement Class Member
for whom I serve in the capacity of an authorized agent.
I hereby submit to the jurisdiction of the United States District Court for the District of New Jersey for all purposes connected with this Claim Form,
including resolution of disputes relating to this Claim Form.