Kardonick v. JP Morgan Chase & Co. et al

Filing 16

STIPULATION Stipulation and Agreement of Class Action Settlement by David Kardonick (Attachments: # 1 Exhibit A, # 2 Exhibit B, # 3 Exhibit C, # 4 Exhibit D, # 5 Exhibit E, # 6 Exhibit F, # 7 Exhibit G, # 8 Exhibit H, # 9 Exhibit I)(Gilbert, Robert)

Kardonick v. JP Morgan Chase & Co. et al

Doc. 16 Att. 6

Kardonick v. JPMorgan Chase & Co., 10-cv-23235 (S.D. Fla.)

CLAIM FORM
To receive benefits from this Settlement, your claim form must be received on or before

.

You must complete all four sections and sign below in order to receive any benefits from this Settlement. 1. CLAIMANT INFORMATION:

________________________________________ __
FNAME1

_____________________________________________ _____________________________________________
LNAME2

MI1 LNAME1

________________________________________ __
FNAME2 MI2

___________________________________________________________________________________________
ADDRESS 1

___________________________________________________________________________________________
ADDRESS 2

________________________________________________________
CITY DATE OF BIRTH ______ / ______ / ___________ 2.

______
STATE

____________ - _________
ZIP ZIP4 (optional)

EITHER state the number that appears on the mailing label of the postcard you received here , OR state the last four , OR state the last four digits of ANY of your Chase credit card accounts digits of your Social Security Number here that were enrolled in a Payment Protection Product at some time between September 1, 2004 and November 11, 2010 here . Please check the box next to the statement that is correct about you: I have been discharged in bankruptcy for the Chase account(s) that were enrolled in a Payment Protection Product. I have not been discharged in bankruptcy for the Chase account(s) that were enrolled in a Payment Protection Product.

3.

4.

Please check all boxes that apply. If you do not check at least one box your claim will not be paid. I made a claim for Chase Payment Protection benefits and my claim was denied. I was billed for or enrolled in a Chase Payment Protection Product without my knowledge or consent and/or I was self-employed, retired, seasonally employed, or employed less than 30 hours per week (or less than 15 hours per week for students), or I voluntarily forfeited my job (resigned) at some point during my enrollment in a Chase Payment Protection Product. None of the above categories apply to me, but I am not completely satisfied with the Chase Payment Protection Product(s) in which I was enrolled at some point between September 1, 2004 and November 11, 2010.

I declare that I have accurately filled out this form to the best of my knowledge.

Name: ________________________________________ Date: ________________________________________

Dockets.Justia.com