Claim Form BLM v. SM

MUST BE POSTMARKED OR RECEIVED NO LATER THAN SEPTEMBER 9, 2024
Black Lives Matter Los Angeles V. City of Santa Monica Case No. 2:20-cv-05253 CAS (AFMx)
CLASS MEMBER CLAIM FORM
Name
Name on Citation if different
Address and Apartment if applicable
City
Zip Code
State
Date of Birth

MonthDayYear
Date
Phone
SS or TIN*
I was 1) present on May 31, 2020/June 1, 2020 in or downtown Santa Monica; 2) I was detained or arrested and issued a criminal citation in connection with protests in response to the the killing of George Floyd in Minneapolis.

Your representations may be checked and are under penalty of perjury. This Claim Form must be postmarked or received by the Administrator NO LATER THAN SEPTEMBER 9, 2024. DO NOT DELAY.

Any information that you provide in this Claim Form is private and will be held in strictest confidence, except as needed by the Parties and for purposes of class administration. It will not be provided to any Government Agency, and will be used solely for purposes of this settlement.

If you have any questions about this lawsuit, contact us at:

LAW OFFICE OF CAROL A. SOBEL, 2632 WILSHIRE BOULEVARD, #552, SANTA MONICA, CA. 90403; by telephone at 424-744-8703, or by email at blmvsmgeorgefloydsettlement@gmail.com, Visit our web site at http://www.blmvsmgeorgefloydsettlement.com

YES, I QUALIFY AND WISH TO MAKE A CLAIM. By signing this form below, I am confirming that the above information is correct and that:

1. I am the person identified above and I am over the age of 18, or, if I am a juvenile, my parent or guardian has signed below.

2. I will abide by, and be limited to, the formula for damages approved by the Court.

3. I will keep the Class Administrator informed of my whereabouts at all times. I declare under penalty of perjury that the information given above is true and correct.
Date

MonthDayYear
Date
Signature [by signing electronically you are certifying that this is your signature and that you are the person identified above or a parent/guardian signing on behalf of the person identified above.]

Clear
Print Name
If you are signing as a Parent or Guardian please print your first and last names on the lines below and include verification of your guardianship status if you are a guardian
Email*
example@example.com
Should be Empty:

MUST BE POSTMARKED OR RECEIVED NO LATER THAN SEPTEMBER 9, 2024

CLASS MEMBER CLAIM FORM