Amount Requested. ❑ The Grantee confirms that the advance is necessary due to a lack of cash on hand to administer the grant on a cost-reimbursable basis. ❑ The Grantee understands the conditions under which AEA will recover the advance. Explain how the advance will be used. Attach additional pages if necessary. Grantee Certification: I certify that the above information is true and correct, and that expenditures will be made for the purpose of, and in accordance with, applicable grant agreement terms and conditions. Signature Date Name and Title Attachment 7 Insurance and Indemnification Waiver
Amount Requested. Required on all applications Applicant / Borrower Signature Date
Amount Requested. $ Please use the online tools for amortization and repayment options.
Amount Requested. $ , . An affidavit must be submitted to support your exact claim amount. Only one (1) form is needed for multiple costs incurred from the Incident. Please provide a brief description of economic loss requested in this Claim, as well as an explanation of how such losses are related to the Data Incident. (You may attach additional pages if necessary). Signature: Date: Your claim will be submitted to the Settlement Print Name: Administrator for review. If your Reimbursement Form is incomplete, untimely, or contains false information, it may be rejected by the Settlement Administrator. If your claim is approved, you will be issued a payment using the email or street address you provide. This process takes time; please be patient. ATTESTED TIME I declare under penalty of perjury that: 🞎 The Attested Time is related to the Incident. Only one (1) form is needed for all Attested Time incurred from the Incident.
Amount Requested. Required on all applications Applicant / Borrower Signature Date 2 Endorsement Box 2a If applicable per page 1 Applicant / Co-Borrower Signature Date
Amount Requested. The Grantee confirms that the advance is necessary due to a lack of cash on hand to administer the grant on a cost-reimbursable basis. The Grantee understands the conditions under which AEA will recover the advance. Explain how the advance will be used. Attach additional pages if necessary. _______________________________________________________________________________________________ _______________________________________________________________________________________________ Grantee Certification: I certify that the above information is true and correct, and that expenditures will be made for the purpose of, and in accordance with, applicable grant agreement terms and conditions. Signature Date Name and Title Attachment 8 Insurance and Indemnification Waiver
Amount Requested. $ , . Documentary proof must be submitted to support your exact claim amount. Please provide a brief description of economic costs requested in this Claim, as well as an explanation of how such losses are related to the Data Incident. (You may attach additional pages if necessary). Date: Your claim will be submitted to the Settlement Administrator for review. If your Reimbursement Form is incomplete, untimely, or contains false information, it may be rejected by the Settlement Administrator. If your claim is approved, you will be mailed a check at the street address you provide. This process takes time; please be patient. Print Name: Signature: REIMBURSEMENT FORMS MUST BE SUBMITTED ONLINE OR POSTMARKED NO LATER THAN DATE TO BE ELIGIBLE FOR PAYMENT. FILE ONLINE AT xxx.XXXXXXXXXXXXX.xxx OR MAIL THIS CLAIM FORM TO ANGEION GROUP, ADDRESS. Exhibit X XXXXXX XXXXXX XXXXXXXX XXXXX XXXXXXXX XXXXXXXX XX XXX XXXX XXXXX XXXXXX, XXXXX XXXXXX, XXXXXXX LUSTIGSON, XXXXXXXX XXXXXXX, and XXXXX XXXXXXXXX, individually and on behalf of all others similarly situated, Plaintiffs,
