I (We) have read and am (are) familiar with the contents of the Instructions accompanying this Claim Form. I (We) certify that the
information I (we) have set forth in the above Proof of Claim and in any documents attached by me (us) are true, correct and
complete to the best of my (our) knowledge. I (We) certify that I (we), or the Class Member(s) I (we) represent, paid the total
amount set forth above in out‐of‐pocket expenditures for purchases or reimbursements Loestrin 24 Fe, Minastrin 24 Fe and/or
their AB‐rated generic equivalents in the United States and its territories from September 1, 2009 through and until September 17,
2019. I (We) further certify that I (we), or the Class Member(s) I (we) represent, did not opt out of the certified Class in this Action.
Nor did I (we), or the represented Class Member(s), purchase such Loestrin 24 Fe, Minastrin 24 Fe and/or their AB‐rated generic
equivalents for purposes of resale. In addition, I (we) have not (or the represented Class Member(s) has not) served as counsel,
officer, director, agent, or employee of the Defendants, or a corporate parent, subsidiary, affiliate, or other related entity thereof;
or served as a judge or justice assigned to hear any aspect of this lawsuit.
To the extent I (we) have been given authority to submit this Proof of Claim by a Class Member(s) on its behalf, and accordingly am
(are) submitting this Proof of Claim in the capacity of an Authorized Agent with authority to submit it by the Class Member(s)
identified on a separate sheet of paper submitted with this form, and to the extent I (we) have been authorized to receive payment
on behalf of this Class Member(s), in the event amounts from the Settlement Fund are distributed to me (us) and a Class
Member(s) later claims that I (we) did not have authority to claim and/or receive such amounts on its behalf, I (we) and/or my
(our) employer will hold the Class, counsel for the Class, and the Settlement Administrator harmless with respect to any claims
made by the Class Member(s).
I (We) hereby submit to the jurisdiction of the United States District Court for the District of Rhode Island for all purposes
connected with the Proof of Claim, including resolution of disputes relating to this Proof of Claim. I (we) acknowledge that any false
information or representations contained herein may subject me (us) to sanctions, including the possibility of criminal prosecution.
I (we) agree to supplement this Proof of Claim by furnishing documentary backup for the information provided herein, upon
request of the Settlement Administrator.
The above-requested claim information, as well as any supporting data as described in Claim Documentation Instructions above, must be submitted electronically on or before September 21, 2020
1. Please complete and sign the above Proof of Claim form. Attach or upload any documentation supporting your
2. Keep a copy of your Proof of Claim form and supporting documentation for your records.
3. If you would also like acknowledgement of receipt of your Proof of Claim form, please complete the form
online or mail this form via Certified Mail, Return Receipt Requested.
4. If you move and/or your name changes, please send your new address and/or your new name or contact
information to the Settlement Administrator by email at info@InReLoestrin24FeAntitrustLitigation.com