Claim Form - Thomas v. California Department of Corrections and Rehabilitation

PART ONE: CLAIMANT INFORMATION

If any of the following information changes, you must promptly notify us by emailing CDCRDataClassActionSettlement@cptgroup.com

First Name

Last Name

Address Line One

Address Line Two

City

State

Zip

Phone Number

Confirm Email

CDCR_ID

PART TWO: CLAIM INFORMATION

PAYMENT METHOD SELECTION

In the event your claim is valid, and you qualify to receive a monetary payment, select the method by which you would like to receive the payment.

I affirm under the laws of the State of California that the information supplied in this Claim Form is true and correct to the best of my knowledge. By signing and submitting this claim form, I assert under penalty of perjury that I reasonably believe I am a member of the class impacted by the breach.

I understand that I may be asked to provide more information by the Settlement Administrator before my claim is complete.

DateSignedOnlineString

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