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Kaiser TCPA Claims Administrator
P.O. Box 43314
Providence, RI 02940-3314
KHS
CLAIM FORM
Rafael David Sherman, individually and on behalf of all others similarly situated v.
Kaiser Foundation Health Plan, Inc., a.k.a. Kaiser Permanente, Case No. 13-cv-00981-JAH-JMA (S.D. Cal.)
You must postmark this Claim Form or submit it online no later than April 3, 2015.
If you are a former Kaiser Foundation Health Plan, Inc. member who received a call on your cell phone from or
on behalf of Kaiser that was made using an automatic telephone dialing system or an artificial or pre-recorded
voice, between April 24, 2009 and December 4, 2014, you could be eligible for a cash payment from this class
action settlement. To complete this Claim Form, provide your name, current address and the cell phone number
called between April 24, 2009 and December 4, 2014 by Kaiser, sign and date the form and submit it online or
mail it postmarked by April 3, 2015 to the address below. You may submit a claim form for each cellular
telephone number called.
Name (Required): First:
Last:
Address (Required): Street:
City:
State:
Zip:
Cellular Number (Required): (____ ____ ____) ____ ____ ____ - ____ ____ ____ ____
Contact Number (if different): (____ ____ ____) ____ ____ ____ - ____ ____ ____ ____
Signature:
Date (mm/dd/yyyy):
Please return this completed Claim Form by mail to:
Kaiser TCPA Claims Administrator
P.O. Box 43334
Providence, RI 02940-3334
KHSPCW1