To be eligible to receive a cash payment under the settlement in Rasnake, et al. v. NetZero, Inc., you
must complete and sign this Claim Form, and send it and any supporting documentation by First Class
or Certified Mail postmarked by December 16, 2008, to:
NetZero Settlement Administrator
P.O. Box 4234
Portland, OR 97208-4234
Important Information About Your Claim
• To be eligible to receive a cash payment from this Settlement, you must meet the following
criteria: (a) you paid charges for your NetZero dial-up internet service account (“NetZero
Account”) after you cancelled the account; and (b) you did not use your NetZero Account after
it was cancelled.
• If you meet the above criteria, and complete and sign this Claim Form, you will be eligible to
receive $10 for the first month you paid charges after cancellation and, if applicable, $8 for the
second month you paid charges after cancellation, up to a maximum total payment of $18.
• If you paid charges for more than two months after cancellation and you provide the information
and documentation described in Step 3 below, you also will be eligible to receive an additional
payment of $8 dollars per month for up to two additional months that you paid charges after
cancellation, up to a maximum total payment of $34.
• If you have any questions regarding your claim, please contact the NetZero Settlement
Administrator at the address listed above. Please do not contact any NetZero customer service
personnel or the Court about your claim; they will not have access to information about your
claim and are not authorized to discuss the Claim Form.
Step 1: Please provide the following information. Failure to provide this information will invalidate
If you have more than one NetZero Account for which you would like to submit a claim,
you will need to submit a separate Claim Form for each account.
Mailing Address: _______________________________________________________________
Email address or login name of your NetZero Account: _________________________________
Step 2: Please answer the following questions.
1. Did you cancel your NetZero Account?
2. Did you pay charges for your NetZero Account after you cancelled the account?
Yes , for ______months No
3. After you cancelled your NetZero Account, did you at any time use your NetZero
Step 3: Please review the following information and complete, if applicable.
If you paid charges for more than 2 months after you cancelled your NetZero Account, you may be eligible
to receive a larger payment, up to a total maximum of $34, if you:
1. Provide the month and year during which you cancelled your NetZero Account:
2. Submit documentation showing that you paid charges after cancellation of your NetZero
Account. Acceptable forms of documentation include any of the following:
• a NetZero cancellation reference number
• any bank, credit card or debit card statement, telephone bill or other financial statement
reflecting a charge by NetZero after the cancellation of your NetZero Account
• any record of a communication with NetZero or a third party (such as your bank, credit
card company, or telephone company) demonstrating that you paid charges for your
NetZero Account after cancellation, or an attempt by you to dispute such charges.
Examples of these records may include a copy of a letter, an email message or notes of
a telephone conversation.
Step 4: Certification
I declare under penalty of perjury that all of the information provided by me in support of my claim,
including any enclosed documentation, is true and correct, to the best of my knowledge.
_________ _________________________________ _________________________________
Date Type or print name Signature
YOU WILL NOT RECEIVE PAYMENT UNLESS YOU FILL OUT AND SUBMIT THIS CLAIM FORM
BY DECEMBER 16, 2008.