ATTESTATION AND SIGNATURE Sample Clauses

ATTESTATION AND SIGNATURE. For and in consideration of ▇▇▇▇▇▇▇.▇▇▇, LLC extending credit to applicant as herein provided, the undersigned do hereby attest the information provided as part of this agreement is for the purpose of obtaining credit and is warranted to be true. The undersigned has read and understands this entire agreement and accept the Terms and Conditions herein stated.

ATTESTATION AND SIGNATURE. Under penalties as provided by law pursuant to Section 1-109 of the Illinois Code of Civil Procedure [735 ILCS 5/1-109], the undersigned certifies that the statements set forth in this instrument are true and correct, except as to matters therein stated to be on information and belief and as to matters the undersigned certifies as aforesaid that he verily believes the same to be true. X Signature of Person Seeking Benefits(or Parent or Legal Guardian if Person Seeking Benefits is a minor) Date Federal regulations require the Mid-America Carpenters Regional Council Health Fund (the Fund) to follow procedures to protect the privacy of your health information within the control of the Fund known as Protected Health Information or PHI. PHI is individually identifiable information or records that the Fund has in any form (paper, electronic, oral) that relates to any one or more of the following: an individual’s mental or physical health status or condition, provision of health care to an individual, or payment for the provision of health care to an individual. The Fund must obtain your authorization before releasing your PHI in those circumstances where the law or the Fund's privacy practices do not otherwise permit or require disclosure. Please use this form for this purpose - it is preferred over other authorizations for release of PHI. SECTION 1: COVERED INDIVIDUAL (PERSON SEEKING BENEFITS) TO WHOM THE PHI RELATES Covered Individual Full Name Date of Birth (MM/DD/YYYY) Person or entity being authorized to provide my PHI: Mid-America Carpenters Regional Council Health Fund (the Fund) and its Business Associates Person or entity being authorized to receive and use my PHI from the Fund: Legal counsel, insurer(s), and/or any third-parties or sources of coverage that may be responsible for payment of medical expenses related to the third-party illness or injury. What types of PHI can be used and disclosed by the Fund? Written, electronic and oral information including claims, reports, and other documents related to claims for benefits for an injury or illness caused by a third-party on from which compensation from a third- party or other source may be obtained. Specific purpose(s) of the use and disclosure of PHI: To allow the Fund to subrogate or obtain reimbursement for the advance of benefits for an injury or illness caused by a third-party or from which compensation from a third-party or other source may be obtained. This authorization will expire on conclusi...

ATTESTATION AND SIGNATURE. I certify under penalty of perjury under the laws of the United States that the information I am providing in this claim form is true and correct, and that I am the cardholder of the card identified in my response to Question Two, above. Name: Signature: Date: SANGER POWERS and ▇▇▇▇▇▇ ▇▇▇▇,individually and on behalf of all others similarly situated, Plaintiffs, v. FILTERS FAST, LLC, Defendant Case No. 3:20-cv-00982-jdp A Final Approval Hearing was held before this Court on , 2021 to consider, among other things, whether the Settlement Agreement and Release dated (the “Settlement Agreement”) (ECF No. ), including the exhibits attached thereto, between Settlement Class Representatives Sanger Powers, ▇▇▇▇▇▇ ▇▇▇▇, ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇▇▇, ▇▇▇▇▇ ▇▇▇▇, and ▇▇▇▇▇ ▇▇▇▇▇▇▇▇▇▇▇, on behalf of themselves and the Settlement Class, and Defendant Filters Fast, LLC (“Filters Fast”), represents a fair, reasonable, and adequate settlement of this case (“the Action”), as well as the amount to be paid to Class Counsel as fees and costs for prosecuting the Action, and the amount to be paid to the Settlement Class Representatives as Service Awards. Based on the Settlement Agreement, the Settlement Class Representatives’ Motion for Final Approval of Class Action Settlement (ECF No. ), the Settlement Class Representatives’ Motion for an Award of Attorneys’ Fees and Expenses and Service Awards for Settlement Class Representatives (ECF No. ), the submissions of the Settlement Class Representatives and Filters Fast in support of final approval of the settlement, and good cause appearing based on the record, the Court ORDERS, ADJUDGES AND DECREES as follows:

ATTESTATION AND SIGNATURE. By filing this claim form, I am certifying that I am a Settlement Class Member and am eligible to make a claim in this settlement and that the information I am providing in this claim form is true and correct. I understand that my claim may be subject to audit, verification, and Court review. I do hereby swear (or affirm), under penalty of perjury, that the information provided above is true and accurate to the best of my knowledge and that any settlement benefits I am claiming are based on expenses and losses I reasonably believe to the best of my knowledge were the result of the Data Breach. Name: Signature: Date:

ATTESTATION AND SIGNATURE. I was enrolled in a Family Sharing group with at least one other person between June 21, 2015 and January 30, 2019, was a U.S. resident during that time, and purchased a subscription to an app (other than one published by Apple) through the App Store during that time. I declare under penalty of perjury that the information provided in this Payment Election Form, to the best of my knowledge, is true and correct.

ATTESTATION AND SIGNATURE. I do hereby swear (or affirm), under penalty of perjury, that the information provided above is true and accurate to the best of my knowledge and that the compensation I am claiming is based on losses I reasonably believe to the best of my knowledge were the result of the Checkers Data Breach. Name: Signature: Date: Case 8:19-cv-01386-VMC-CPT Document 43-1 Filed 05/06/20 Page 68 of 81 PageID ▇▇▇ ▇▇▇▇▇▇▇▇ ▇▇▇▇▇▇ and ▇▇▇▇ ▇▇▇▇,individually and on behalf of others similarly situated, Plaintiff, v. CHECKERS DRIVE-IN RESTAURANTS, INC.,a Delaware corporation, Defendant. Case No.: 8:19-cv-01386-VMC-CPT Class Action This matter came before the Court on Plaintiffs’ Unopposed Motion for Final Approval of Class Action Settlement and entry of final judgment (“Motion”). On , the Court entered an Order preliminarily approving the proposed Settlement pursuant to the terms of the Parties’ Settlement Agreement and directing that notice be given to the Settlement Class (the “Preliminary Approval Order”). On , pursuant to the notice requirements set forth in the Settlement Agreement and the Preliminary Approval Order, the Settlement Class was notified of the terms of the proposed Settlement Agreement, of the right of Settlement Class Members to opt-out, and the right of Settlement Class Members to object to the Settlement Agreement and to be heard at a Final Approval Hearing. On , the Court held a Final Approval Hearing to determine, inter alia: (1) whether the terms and conditions of the Settlement Agreement are fair, reasonable, and adequate for the release of the claims contemplated by the Settlement Agreement; and (2) whether judgment should be entered dismissing this action with prejudice. Therefore, the Court is satisfied that Settlement Class Members were properly notified of their right to appear at the Final Approval Hearing in support of or in opposition to the proposed Settlement Agreement, the award of attorneys’ fees and costs to Class Counsel, and the payment of Service Awards to the Representative Plaintiffs. Having given an opportunity to be heard to all requesting persons in accordance with the Preliminary Approval Order, having heard the presentation of Class Counsel and counsel for Defendant, having reviewed all of the submissions presented with respect to the proposed Settlement Agreement, having determined that the Settlement Agreement is fair, adequate, and reasonable, having considered the application made by Class Counsel for attorneys’ fees and costs...

ATTESTATION AND SIGNATURE. You must certify that the information you provided above is true and accurate. Please sign the following: I declare under penalty of perjury under the laws of the United States that the information supplied in this Claim Form is true and correct to the best of my recollection. I understand that I may be asked to provide supplemental information by the Claims Administrator before my claim will be considered complete and valid. Print Name: Signature: Date: The deadline to submit this Claim Form and all required supporting documentation is : This Claim Form may be submitted online at ▇▇▇.▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇▇.▇▇▇ or completed and mailed to the address below. Please type or legibly print all requested information, in blue or black ink. Mail your completed Claim Form, along with any supporting documentation, by U.S. Mail to: Settlement Administrator Street A settlement has been reached with SEIU 32BJ in a class action lawsuit about a data security incident (“Incident”). A lawsuit was filed asserting claims against SEIU 32BJ relating to the Incident. SEIU 32BJ denies all of the claims and says it did not do anything wrong. What Happened? Plaintiffs allege that a third party allegedly gained access to certain of SEIU 32BJ’s computer systems between October 21, 2021 and November 1, 2021 which contained the protected identifying information (“PII”) of SEIU 32BJ’s current and former members and employees, including their names, addresses, dates of birth and social security numbers. WHO IS INCLUDED? You received this email because SEIU 32BJ’s records show you are a member of the Settlement Class. The Settlement Class includes all residents of the United States whose PII was potentially compromised in the Incident.

ATTESTATION AND SIGNATURE. I hereby declare under penalty of perjury that the information I have provided is true and correct. SIGNATURE DATE QUESTIONS? CALL [PHONE NUMBER] TOLL FREE 2