Step 1 of 4 - Claimant Information 25% Claim FormPhelps v. Toyotetsu North America, Inc., Case No. 6:22-cv-00106 United States District Court, Eastern District of Kentucky SUBMIT BY AUGUST 23, 2023 ONLINE OR MAIL TO: Phelps v. Toyotetsu North Americac/o Atticus AdministrationPO Box 64053St. Paul, MN 55164Email: ToyotetsuDataSettlement@atticusadmin.com GENERAL CLAIM FORM INFORMATION This Claim Form should be filled out online or submitted by mail if you were sent notice about a data security incident Defendant Toyotetsu experienced around October 2021 ("Settlement CLass"). If you wish to submit a Claim by mail, please download a copy HERE. Please print clearly in blue or black ink. This Claim Form must be mailed and postmarked by no later than August 23, 2023.ClaimFormNoClaimant InformationName* First Middle Initial Last Mailing Address* Street Address Address Line 2 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 Current Phone Number*Current Email Address* Claimant ID* Monetary CompensationCash Payment: Would you like to receive a cash payment under the Settlement? *Cash Payment: Would you like to receive a cash payment under the Settlement?* Yes No ** The $250 cash payments may be increased or decreased pro rata to the extent there are funds remaining in the Settlement Fund.Out-of-Pocket Expenses (if any): I am submitting a claim for either ordinary or extraordinary monetary losses on account of out-of-pocket expenses and/or extraordinary losses I incurred as a result of the Data Incident in the amount ofon account of out-of-pocket expenses and/or extraordinary losses I incurred as a result of the data security incident involving Toyotetsu (“Data Incident”). I understand that I am required to provide supporting third-party documentation and to support my claim for out-of-pocket losses, such as providing copies of any receipts, bank statements, reports, or other documentation supporting my claim. This can include receipts or other documentation not “self-prepared” by you. “Self-prepared” documents such as handwritten receipts are, by themselves, insufficient to receive reimbursement, but can be considered to add clarity or support other submitted documentation. The Settlement Administrator may contact you for additional information before processing your claim. If you do not have information supporting your claim for ordinary or extraordinary expenses, you likely will not receive compensation for this settlement benefit. Any monetary compensation you may receive under the settlement is capped at $5,000.00 for out-of-pocket expenses.Supporting Documents for Out-of-Pocket expenses Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, docx, doc, xlsx, xls, Max. file size: 16 MB, Max. files: 9. Description of the unreimbursed, out-of-pocket loss occurred, and the documents attached to support this claim:No benefits selected* You have not selected any claim benefits. Please select a claim benefit above before proceeding. How You Would Like to Receive Your Cash Payment If you made a claim for a cash payment in this claim form, you could elect to receive your payment either by check or as a digital payment. Payments must be cashed within ninety (90) days. Choose your payment method below. Payment Method* HiddenPayment Token AcknowledgementCredit Monitoring Acknowledgement* I am submitting this claim for monetary losses and your representations of these losses are true and correct to the best of your knowledge and belief. I declare under penalty of perjury under the law of the United States of America that the foregoing is true and correct. Typed Signature Name* CAPTCHAUnique IDCommentsThis field is for validation purposes and should be left unchanged.
