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- Between May 1, 2009 and December 31, 2019, did you pay for all or part of the price (a co-pay counts) of any of the listed generic drugs, for yourself or your family (not to resell), in any U.S. state except Indiana and Ohio, or in the District of Columbia, Puerto Rico or the U.S. Virgin Islands?*
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- Do any of these apply to you? (check all that apply)*
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- Have You submitted a request to exclude Yourself, or "opt out of," the Generic Drugs End-Payer Settlements (Sandoz and Sun/Taro).*
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Format: (000) 000-0000.
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- Date of Birth*
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?*
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Did you take another drug on the list?
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- Do you know the total amount you paid from your pocket for this drug from May 1, 2009 - December 31, 2019?
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- Have you ever sent in a claim for this generic drugs settlement before?*
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- If YES: How was it filed?
- If YES: When did you file it? (approximate is fine)
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- Your records: which one is true for you?*
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- By completing and signing this intake form, I acknowledge and agree that: I am providing my information to T.K. Sheth Law LLC d/b/a The Law Shed for the purpose of pursuing a claim in the Generic Drugs End-Payer Settlements (Sandoz and Sun/Taro). I authorize The Law Shed to prepare, sign, and submit my claim form to the Claims Administrator on my behalf, and to communicate with the Claims Administrator regarding my claim. The information I have provided is true, accurate, and complete to the best of my knowledge, information, and belief. I understand that The Law Shed, the Claims Administrator, or Class Counsel may request additional information or documentation to support my claim, and I agree to provide it if requested. I consent to be contacted by The Law Shed electronically, including by email and/or mobile text message (message & data rates may apply), regarding this claim and related representation.*
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- Should be Empty: