O'Bannon, Jr. v. National Collegiate Athletic Association et al
Filing
288
Joint Filing of Amended Settlement Agreements and Exhibits Thereto by Samuel Michael Keller (Attachments: #1 Exhibit 1, #2 Exhibit 2, #3 Exhibit 3, #4 Exhibit 4, #5 Exhibit 5)(Carey, Robert) (Filed on 7/24/2014) Modified on 7/25/2014 (cpS, COURT STAFF).
EXHIBIT 5
Must Be
Submitted By
_______________
CLAIM FORM:
Electronic Arts (“EA”) and NCAA Videogame Settlements
To Be Eligible to Receive Benefits under the Settlements Described in the Enclosed Notice,
You Must Complete this Claim Form by __________.
Please read this Claim Form and the enclosed Notice carefully.
If you would like to receive a payment under the EA and/or NCAA Videogame Settlements, you must submit this Claim
Form according to the instructions.
REQUESTING OR RECEIVING A PAYMENT UNDER THESE SETTLEMENTS
WILL NOT AFFECT YOUR NCAA ELIGIBILITY.
You can submit one Claim Form for both settlements. You do not need to submit a separate Claim Form for each
settlement in which you wish to make a Claim. See Question 2 (below) for more details.
You have two options for submitting a Claim Form—Online or By Mail:
Submit a Claim Form Online:
Submit a Claim Form by Mail:
You may submit a claim online by visiting
www._______________settlement.com and filling out this
Claim Form by __________________.
You may submit a claim by completing this Claim Form,
signing it, and mailing it so that it is postmarked by
_________________ to the following address:
[TBD]
If you need any help with this Claim Form, or with any other questions regarding these settlements, please call the
Settlement Administrator at 1-___-___-___ toll-free, visit www.________________settlement.com, or e-mail
______________________settlement.com.
After your claim is processed, you will receive a letter telling you whether you are eligible for a payment and, if so, the
letter will include a check for the amount of the payment. The letter will also explain the process and deadlines to resolve
any disagreement you may have with the decision about your eligibility for a payment. Please be patient, as this process
could take some time.
PLEASE DO NOT CALL THE COURT, THE JUDGE, THE CLERK OF COURT, EA, OR THE NCAA
REGARDING THIS MATTER.
QUESTIONS? CALL 1-___-___-____ TOLL-FREE OR VISIT www.___________ settlement.com.
Must Be
Submitted By
_____________
CLAIMANT ID BARCODE WILL
APPEAR HERE
1: PROVIDE CLASS MEMBER INFORMATION.
Last Name:
First Name:
Middle Initial:
Mailing Address:
City:
State:
Daytime Phone:
—
Zip Code:
Evening Phone:
—
—
—
E-Mail Address:
2. DO YOU WANT TO MAKE A CLAIM IN BOTH SETTLEMENTS?
If you send in a Claim Form, we will assume that you want to make a claim in BOTH the EA Settlement and the NCAA
Settlement, unless you tell us otherwise by checking one of the boxes below.
Please remember that you may not submit a claim in a settlement in which you have excluded yourself. If you exclude
yourself from a settlement, you will not get a payment from that settlement. See Question __ of the enclosed Notice for
more details.
If you want to make a claim in both Settlements, skip to Question 3, below.
If you want to make a claim in only one of the Settlements, please check below:
o I want to make a claim ONLY in the EA Settlement.
o I want to make a claim ONLY in the NCAA Settlement.
The only way to get a payment under these settlements is to submit a claim. If you decide NOT to make a claim in
either settlement and you do not exclude yourself, you will NOT get any payment from that settlement AND you will be
giving up legal rights.
QUESTIONS? CALL 1-___-___-____ TOLL-FREE OR VISIT www._____________________settlement.com.
Must Be
Submitted By
_____________
CLAIMANT ID BARCODE WILL
APPEAR HERE
3. PROVIDE SOME INFORMATION ABOUT YOURSELF
FOR EACH COLLEGE OR UNIVERSITY YOU ATTENDED, PLEASE PROVIDE THE FOLLOWING INFORMATION. If
you don’t know whether you were on the team roster, include the years that you attended school and played NCAA
Division I men’s basketball or football.
If you need more space, feel free to include additional pages with your Claim Form.
COLLEGE
OR
UNIVERSITY
YEAR(S)
LISTED
ON
NCAA
THE
SPORT(S)
FOR
D-‐1
MEN’S
BASKETBALL
OR
WHICH
YOU
WERE
FOOTBALL
TEAM
ROSTER
LISTED
ON
A
ROSTER
POSITION(S)
AND
JERSEY
NUMBER(S)
YOUR
HOME
STATE
(as
listed
on
school
roster—NOT
your
current
home
state)
4. PROVIDE ADDITIONAL INFORMATION, IF YOU KNOW
If you know, list all seasons/editions of an NCAA-Branded Videogame published by EA—(1) “NCAA Football,” (2) “NCAA
Basketball,” or (3) “NCAA March Madness” (any videogame platform)—in which you believe that your jersey number
and/or photograph appears. This information is not necessary to make a claim, but it may help us in processing your
claim.
If you need more space, feel free to include additional pages with your Claim Form.
NAME
OF
VIDEOGAME
SEASON/EDITION/
YEAR
OF
VIDEOGAME
DOES
YOUR
JERSEY
NUMBER
APPEAR
IN
THIS
VIDEOGAME?
DOES
YOUR
PHOTOGRAPH
APPEAR
IN
THIS
GAME?
If you are the Class Member, DO NOT FILL OUT THE NEXT QUESTION (#5). INSTEAD, GO TO THE LAST PAGE
(“CERTIFICATION”) AND SIGN YOUR CLAIM FORM.
QUESTIONS? CALL 1-___-___-____ TOLL-FREE OR VISIT www._____________________settlement.com.
Must Be
Submitted By
_____________
CLAIMANT ID BARCODE WILL
APPEAR HERE
If you are filling out this Claim Form on behalf of a Class Member (for example, if you have power of attorney over the
Class Member’s affairs), fill out Step 5.
5. INFORMATION TO BE PROVIDED BY EXECUTORS, ADMINISTRATORS, GUARDIANS, PERSONAL
REPRESENTATIVES, OR OTHERS LEGALLY AUTHORIZED TO PROVIDE CLASS MEMBER INFORMATION.
(a) Are you the personal representative of a deceased Class Member?
Yes O
No O
/
If so, provide the date of the Class Member’s death:
/
(b) Are you a guardian, conservator, or attorney in fact of an incapacitated Class Member?
Yes O
No O
(c) Are you the legally appointed representative (for example, through a power of attorney) responsible for handling
the Class Member’s business affairs?
Yes O No O
Please provide YOUR information:
Last Name
First Name
Mailing Address
City
Daytime Phone Number:
State
—
Zip Code
—
E-Mail Address:
IMPORTANT: If you are submitting this claim on behalf of the Class Member, please also submit with this Claim Form
documents to prove that you are authorized to submit this Claim Form on behalf of that Class Member (for example,
estate documents, powers of attorney, death certificates, etc.).
QUESTIONS? CALL 1-___-___-____ TOLL-FREE OR VISIT www._____________________settlement.com.
Must Be
Submitted By
_____________
CLAIMANT ID BARCODE WILL
APPEAR HERE
CERTIFICATION:
I certify under penalty of perjury that I have read this Claim Form; I believe I am a Class Member or the Legally
Authorized Representative of a Class Member; and all of the information on this Claim Form is true and correct to the
best of my knowledge.
Print Name
Signature
Date
(MM)
(DD)
(YY)
QUESTIONS? CALL 1-___-___-____ TOLL-FREE OR VISIT www._____________________settlement.com.
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