TCPA CLASS ACTION SETTLEMENT CLAIM FORM

Berdon Claims Administration LLC | Website: | Toll-Free Phone: (800) 766-3330 TCPA CLASS ACTION SETTLEMENT CLAIM form In order to receive benefits from this SETTLEMENT , you must provide all of the information below and sign this CLAIM form . Your CLAIM form must be postmarked on or before February 13, 2015. Late CLAIM forms will not be considered. I. CLAIMANT INFORMATION Claimant Name: _____ Mailing Address: _____ _____ _____ Telephone Number (Day): _____ E-mail Address: _____ Did you receive one or more text messages promoting the services of Swedish Medical or Universal Men s Clinic in February or March 2013 without your consent? [ ] YES | [ ] NO If the answer is yes, provide the cellular telephone number at which such message(s) were received: _____ II.

Berdon Claims Administration LLC | Website: www.berdonclaims.com | Toll-Free Phone: (800) 766-3330 TCPA CLASS ACTION SETTLEMENT CLAIM FORM In order to receive benefits from this settlement, you must provide all of the information below and sign this claim

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