CLASS ACTION CLAIM FORM Vinson v. Verizon Directories Corp., Case No. INC055768
Vinson v. Verizon Directories Settlement Administrator PO Box 9349 Minneapolis, MN 55440-9349
FOR IDENTIFICATION PURPOSES, WRITE YOUR NAME AND ADDRESS HERE:
_____________________________________________ _____________________________________________ _____________________________________________
INSTRUCTIONS FOR COMPLETING THIS FORM
1. 2. 3. Fill out all parts of this claim form completely. Your claim may be rejected if you provide incomplete or inaccurate information. You may submit only one claim per person or business. Answer all questions on behalf of the business for which the Yellow Pages advertising referenced below was purchased, unless you are a certified marketing representative, in which case answer all questions on behalf of yourself as a certified marketing representative. You may submit this claim form online or by mail. An online copy can be found at www.DirectoriesSettlement.com, and can be submitted by clicking on the “Submit” button at the end of the form. To submit it by mail, send it by United States mail, postage prepaid, to the Vinson v. Verizon Directories Settlement Administrator, PO Box 9349, Minneapolis, MN 55440-9349. Claim forms that are submitted online must be submitted by March 12, 2008, at 11:59 p.m. Pacific Standard Time, and a claim form will be rejected if submitted after that time or if it is incomplete. Claim forms that are submitted by mail must be postmarked by March 12, 2008, and a claim form will be rejected if postmarked after that date or if it is incomplete. If you are the successor-in-interest or heir of the person or entity that purchased Yellow Pages advertising in the directories listed below, then you must submit this claim form by mail instead of online, and must enclose documentation establishing that you are the successor-in-interest or heir and that you now hold any claims relating to the timing of the distribution of the directories.
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PART A – CLAIMANT INFORMATION ___________________________________________
Business (or Certified Marketing Rep.) Name
___________________________________________
Mailing Address
___________________________________________
City
___________________________________________
State and Zip Code
___________________________________________
E-mail Address
___________________________________________
Phone Number
________________________________________
Social Security Number or Taxpayer ID Number
If you are the successor-in-interest or heir of the business or certified marketing representative listed above, provide your name, complete mailing address, phone number, and e-mail address: __________________________________________
__________________________________________________________________________________________
PART B – CLAIM DETAILS
Answer each of the following questions by checking the appropriate box: 1. Did you purchase advertising in any of the following Verizon Directories Corp. Yellow Pages print directories: (a) the directory for the Palm Springs, California area dated 2004 (the “Palm Springs Directory”); (b) the directory for the Indio, California area dated 2004 (the “Indio Directory”); or (c) the Coachella Valley Mobile Guide directory dated 2004-2005 (the “Coachella Valley Directory”)?
Yes
2.
No
Did you pay all your bills in full for any and all advertising you purchased in the three directories listed above?
Yes
3.
No
Have you received any credit or other compensation from Verizon Directories Corp., Verizon Information Services, or Idearc Media Corp. in response to any claim or complaint you made concerning the timing of the distribution of any of the three directories listed above?
Yes
No
PART C – COMPENSATION ELECTION
If your claim is approved, then you will become entitled to one and only one of the following forms of compensation. Check the box beside the form of compensation you would prefer to receive. Check only one box. A check in an amount that is equal to the sum of: (a) 5.2178% of the total amount you paid for 12 months of advertising in the Palm Springs Directory; (b) 3.8446% of the total amount you paid for 12 months of advertising in the Indio Directory; and (c) 6.0363% of the total amount you paid for 12 months of advertising in the Coachella Valley Directory. A coupon that will entitle you to a discount for advertising in a future edition of the Verizon Yellow Pages print directories for Palm Springs, Indio, or Coachella Valley, California, such discount to have a retail value equal to 200% of the amount you otherwise would be entitled to receive pursuant to the formula in the preceding paragraph. For further details concerning the coupon and its permitted use, including important limitations, please refer to the class action Notice you received in the mail and that is available at www.DirectoriesSettlement.com, and the full settlement agreement available at www.DirectoriesSettlement.com.
PART D – CERTIFICATION
Do you certify under penalty of perjury that the information you provided above is true and correct to the best of your knowledge, information, and belief?
Yes
No
____________________________________________ Signature (if submitting claim form by mail)