Dancer Litigation

Proof of Claim Form (can be completed and submitted on-line)

www.DancerLitigation.com

To receive any relief to which you are entitled, please complete this form online no later than 11:59 p.m. on April 8, 2014.  Forms submitted after this deadline will not be accepted.

You may also print a copy of this form, complete the requested information, and return it to Dancer Litigation, Settlement Administrator, P.O. Box 11486, Birmingham, AL 35202-1486 no later than April 8, 2014.  Form that are not postmarked by April 8, 2014, will not be accepted.

First Name:   *

Last Name:   *

Country:       *

Address:       *

City:             *

State:            *

Zip:              *

By submitting a claim form and seeking payment, you certify the following:

I received one or more calls from or on behalf of Los Angeles Times at the following cellular telephone number(s).  I did not consent to receive autodialed calls from or on behalf of Los Angeles Times:

*

Check the box next to each claim for which you wish to be considered.  By checking any box, you are attesting that the statement that follows it is true.

IF YOU WISH TO SUBMIT A CLAIM FOR PAYMENT, PLEASE CHECK ONE OF THE FOLLOWING BOXES (see Section 9 of the Class Notice for payment amounts)

I received one or more telephone calls from or on behalf of Los Angeles Times at the above listed cellular telephone number(s).  I understand I will not be required to submit telephone bill records to verify the number of calls that I received.

I received five to ten telephone calls from or on behalf of Los Angeles Times at the above listed cellular telephone number(s).  I understand I may be required to submit telephone bill records to verify the number of calls I received.

I received more than ten telephone calls from or on behalf of Los Angeles Times at the above listed cellular telephone number(s).  I understand I may be required to submit telephone bill records to verify the number of calls I received.

Even if you have no claim for payment, you have the right to request not to be called by or on behalf of Los Angeles Times.

FOR CALL RECIPIENTS WHO WISH NOT TO BE CALLED BY OR ON BEHALF OF LOS ANGELES TIMES 

I elect not to receive any calls from or on behalf of Los Angeles Times at the following telephone number(s):

I swear (or affirm) that the above statements are true and correct to the best of my knowledge under penalty of perjury of the laws of the State of California.

Claimant Name:

By typing your name above and submitting your claim form, you are electronically signing your name and attesting to the above information.

required fields are marked with an asterisk *