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  • INDIVIDUAL CLASS MEMBER CLAIM FORM

    Fonseca, et al., v. Dircksen & Talleyrand,Inc. et al., Case No. 13 CV 5125 (SN)

    TO SHARE IN THE SETTLEMENT, YOU MUST COMPLETE,
    SIGN AND RETURN THIS CLAIM FORM. YOU WILL NOT RECEIVE ANY PAYMENT
    FROM THE SETTLEMENT UNLESS YOU SUBMIT THIS CLAIM FORM.
    THE CLAIM FORM MUST BE POSTMARKED NO LATER THAN DECEMBER 22, 2017
  • CORRECTIONS OR ADDITIONAL INFORMATION

  • Write any name and address corrections below if any is necessary OR if there is no preprinted data to the left, please provide your name and address here:
  • MAIL TO: Fonseca v. Dircksen & Talleyrand,Inc. c/o Arden Claims Service, LLC P.O. Box 1015 Port Washington, NY 11050 877-623-2703 Tel 516-944-1771 Fax info@ardenclaims.com Email
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