Payment Forms must be submitted by June 18, 2018.
May we contact you by telephone or email?
Did you or someone in your household have this telephone number between May 11, 2010 and August 1, 2011?
IF “Yes,” who was your telephone provider (for example, Verizon, AT&T) at that time?
If you have a telephone bill or other documents showing that you or someone in your household had this number, please upload a copy. If you do not have these kinds of documents, that’s OK; please certify and submit
this form, and the Claims Administrator will contact you to help you complete your claim for payment.
Maximum file size: 10 mb
Allowed file types: .jpg, .jpeg, .tif, .tiff, .gif, .png, .pdf
If “No”, you are not eligible to receive a payment. Please certify and submit the form below.
If you know who had this number in 2010-2011, please identify that person, and include any contact information you may have: