Levine v. Citibank N.A.

Filing 173

PRELIMINARY APPROVAL ORDER. The deadline to submit a claim, to object, and to opt out is January 31, 2013. The Final Approval Hearing shall be held on March 15, 2013. Signed by Judge Maxine M. Chesney on November 6, 2012. (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C) (mmclc1, COURT STAFF) (Filed on 11/6/2012) Modified on 11/6/2012 (mmclc1, COURT STAFF).

CLAIM FORM
In re Citibank HELOC Reduction Litigation
Submit this Claim Form Online at https://www.inrehelocsettlement.com or
return this Claim Form to: In re Citibank HELOC Litigation, Settlement Administrator
PO Box 2838, Portland, OR 97208-2838,
Questions? Visit https://www.inrehelocsettlement.com or call 1-866-487-6522

DEADLINE: THIS CLAIM FORM MUST BE SUBMITTED ONLINE OR
POSTMARKED BY JANUARY 31, 2013
Instructions: Mail this form only if all of the following are true. You: (1) were a Citibank HELOC customer during the
period from January 1, 2008 through January 31, 2012; (2) closed your HELOC account in response to Citibank’s
suspension or reduction of your HELOC based on Citibank’s claim that your home value significantly declined in value;
and (3) paid an early closure release fee to Citibank.
Each person seeking a cash benefit under the Class Action Settlement Agreement must complete a paper claim form. You
can only submit one claim form for each HELOC you closed in response to Citibank’s suspension or reduction of your
HELOC account. Only former named account holders may file a claim form. Where there are multiple
accountholders named on a single account, only one claim form may be filed. If any co-borrower on your account
requests to be excluded from the Settlement, the claim will be deemed invalid. For further information, please visit
www.inrehelocsettlement.com, or call 1-866-487-6522
To submit a claim for a cash benefit, begin by filling in all of the information requested in Part A. Once complete, move
on to Part B and check each and every box that applies to you. Once all of the boxes are checked, review and sign the
Certification under Part C.
After the form is completed, submit it online at https://www.inrehelocsettlement.com or mail it to the Settlement
Administrator at In re Citibank HELOC Litigation, Settlement Administrator, PO Box 2838, Portland, OR 97208-2838.
All claim forms must be submitted online or postmarked by January 31, 2013.

PART A - CLAIMANT INFORMATION*
Name: _______________________________
(First)

________
(Middle)

_________________________________
(Last)

Address: ________________________________________________________________________
(Street)
________________________________________
____ ____
____ ____ ____ ____ ____
(City)
(State)
(Zip Code)

Phone Number: ( ___ ___ ___) ___ ___ ___ – ___ ___ ___ ___

Address of property serving as security for Citibank HELOC (if different from address above):
_______________________________________________________________________________________
(Street)
________________________________________
____ ____
____ ____ ____ ____ ____
(City)
(State)
(Zip Code)
Contact Phone Number: ( ___ ___ ___) ___ ___ ___ – ___ ___ ___ ___
Please provide a phone number where you can be reached if further information is required.
Email Address: ____________________________________________
* All information in this section is required.

PART B – EARLY CLOSURE RELEASE FEE INFORMATION
Cash Refund for Payment of Early Closure Release Fee
By submitting a claim form, I verify that I believe I am a member of the Class and that the following statements are true:
I was a Citibank HELOC customer in the United States, and my HELOC was suspended or reduced by Citibank
based on a claim that my home value significantly declined.
As a result of Citibank’s suspension or reduction of my HELOC, I closed my HELOC account.
In closing my Citibank HELOC account, I paid Citibank an early closure release fee.
Failure to check all three boxes may result in the denial of your claim.

PART C – CERTIFICATION UNDER PENALTY OF PERJURY
I declare under penalty of perjury that I believe I am a member of the Class, and all of the information in this Claim
Form is true and accurate.

Signature: _________________________________

Date: _________________________________

Print Name: ________________________________

If approved you will be entitled to a cash award of
$120.00.

Questions? Visit https://www.inrehelocsettlement.com or Call 1-866-487-6522