Step 1 of 5 - PERSONAL INFORMATION 20% CLAIM FORM Tarrant v. Southland Holdings LLC., No. 067-333679-22 The DEADLINE to submit this Claim Form is: April 22, 2024 GENERAL INSTRUCTIONS If your Private Information (name, address, Social Security number, and driver's license number and additional Personally Identifiable Information) was compromised or potentially compromised in the Data Security Incident, you are a “Settlement Class Member.” If you received a Notice about this class action Settlement addressed to you, then the Settlement Administrator has already determined that you are a Settlement Class Member. As a Settlement Class Member, you are eligible to receive thirty months of credit monitoring services, or (2) a cash payment. You are also eligible to receive compensation for documented unreimbursed economic losses. CLAIMANT INFORMATION The Claims Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes before the Settlement benefits are issued, you must notify the Claims Administrator ClaimFormNoName* First M.I. Last Alternative Name(s) Address* Mailing Address, Line 1: Street Address/P.O. Box Mailing Address, Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code Telephone Number (Home)*Telephone Number (Mobile)Email* Date of Birth Unique ID* HiddenHiddenLastName* BENEFIT SELECTION You may select 30 months of Credit Monitoring OR an Alternative Compensation of $35.00. You may also select cash compensation for PII misused for fraudulent loan applications, misused for fraudulent credit card application, denial of funding due to flagged credit, or identity theft/fraudulent tax returns CREDIT MONITORING: If you wish to receive 30 months of Credit Monitoring Services, check the box below, provide your email address (on the previous page), sign, and return this Claim Form. Submitting this Claim Form will not automatically enroll you in Credit Monitoring Services. To enroll, you must follow the instructions that will be sent to you using the email address you provided (on the previous page) after the Settlement is approved and becomes final (the “Effective Date”). Receive Credit Monitoring Service I would like to receive 30 months of Credit Monitoring Services. I have provided my email address on the previous page. ALTERNATIVE COMPENSATION As an alternative to the credit monitoring (and not in addition to), if you wish to receive a $35.00 cash payment, check the box below: Alternative Compensation I would like to receive a $35.00 cash payment and decline the Credit Monitoring Services. I confirm that I have taken other actions appropriate to protect my credit and personal data. 3. COMPENSATION FOR MISUSE OF DATA: In addition to claiming the credit monitoring OR the alternative compensation, you may choose to claim the monetary benefits offered below if you qualify to do so. You may only choose one of these payments, even if you suffered multiple forms of misuse of your data. A. Compensation for Fraudulent Loan Applications: If your name, address, Social Security Number, and/or driver's license number were used to apply for and/or finalize loan applications as a result of the Data Breach, you may claim $80.00 including the time spent dealing with Data Breach; Receive Claim A: Compensation for Fraudulent Loan Applications I attest, swear, and affirm that between September 21, 2021, to the present, I experienced fraudulent lines of credit (via loan or credit card) or attempted lines of credit (via loan or credit card) resulting from the Data Breach, and claim $80.00. NOTE: You must include documentation supporting your claim for Fraudulent Loan Applications. An example of the documentation required would be a letter from a bank or credit card company confirming that a fraudulent loan was applied for in your name. Handwritten, or self-prepared receipts are, by themselves, not sufficient to receive reimbursement, but can be considered to add clarity to or support other submitted documentation. B. Compensation for Fraudulent Credit Card Applications: If your name, address, Social Security Number, and/or driver's license number were used to apply for and/or finalize credit card applications as a result of the Data Breach, you may claim $125.00 including the time spent dealing with Data Breach; Receive Claim B: Compensation for Fraudulent Credit Card Applications I attest, swear, and affirm that between September 21, 2021, to the present, I experienced fraudulent lines of credit (via loan or credit card) or attempted lines of credit (via loan or credit card) resulting from the Data Breach, and claim $125.00. NOTE: You must include documentation supporting your claim for Fraudulent Credit Card Applications. An example of the documentation required would be a letter from a bank or credit card company confirming that a fraudulent credit card was applied for in your name. Handwritten, or self-prepared receipts are, by themselves, not sufficient to receive reimbursement, but can be considered to add clarity to or support other submitted documentation. C. Compensation for Denial of Funding Due to Flagged Credit: If you were denied funding due to flagged credit as a result of the Data Breach, you may claim $125.00 including the time spent dealing with Data Breach. Receive Claim C: Compensation for Denial of Funding Due to Flagged Credit I attest, swear, and affirm that between September 21, 2021, to the present, I was denied funding (via loan or credit card) due to flagged credit resulting from the Data Breach, and claim $125.00. NOTE: You must include documentation supporting your claim for Denial of Funding Due to Flagged Credit. An example of the documentation required would be a letter from a bank or other financial services company confirming that you were denied funding due to your flagged credit. Handwritten, or self-prepared receipts are, by themselves, not sufficient to receive reimbursement, but can be considered to add clarity to or support other submitted documentation. D. Compensation for Identity Theft or Fraudulent Tax Returns: If your name, address, Social Security Number and/or driver's license number was accessed (or may have been accessed) during the Data Breach and you experienced identity theft and/or false/fraudulent tax returns after September 21, 2021, you may claim $250.00 including the time spent dealing with Data Breach; Receive Claim D: Compensation for Identity Theft or Fraudulent Tax Returns I attest, swear, and affirm that between September 21, 2021, to the present, I experience(d) identity theft and/or false/fraudulent tax returns, and claim $250.00. NOTE: You must include documentation supporting your claim for Identity Theft or Fraudulent Tax Returns. An example of the documentation required would be a letter from the Internal Revenue Service (IRS) confirming that a tax return was filed in your name that did not belong to you. Handwritten, or self-prepared receipts are, by themselves, not sufficient to receive reimbursement, but can be considered to add clarity to or support other submitted documentation. Upload Supporting Documents for Claim* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, Max. file size: 16 MB, Max. files: 20. BENEFIT SUMMARY Below is a summary of the claims you have elected on this claim form. Please verify before proceeding. If you did not elect any claim benefits, please go back and select your claim benefit before proceeding. * Alternative Compensation: $35.00 cash payment and decline the Credit Monitoring Services * 30 months of Credit Monitoring * Claim A: Compensation amount of $80.00 for Fraudulent Loan Applications * Claim B: Compensation amount of $125.00 for Fraudulent Credit Card Applications * Claim C: Compensation amount of $125.00 for Denial of Funding Due to Flagged Credit * Claim D: Compensation amount of $250.00 for Identity Theft or Fraudulent Tax Returns Southland Payment OptionPlease select the Payment Option by which you would like to receive your payment and complete the steps as prompted. Chosen Payment Method* HiddenPayment Token* Unique IDAcknowledgement* I swear and affirm that the foregoing is true and correct. I also attest that I am (or have been in the past three (3) years) an employee, or former employee of Southland who was employed on or before September 21, 2021.