CLAIM FORM

HERNANDEZ, ET AL. V. EXPERIAN INFORMATION

SOLUTIONS, INC., ET AL.

CONTENTS
General Instructions
01
Claimant Information
02
Claim Details
03
Actual Damage Details
04
Reminder Checklist
05

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 I. GENERAL INSTRUCTIONS
In order for your claim to be considered, you must fully complete this Claim Form. Type or legibly print all
information in blue or black ink, answering all questions below. If you are submitting an Actual Damages Claim,
please sign and date the certification. Please submit the completed Claim Form, including any documentation
that may be required, to the Settlement Administrator by First-Class mail, postmarked on or before
November 13, 2017, at the following address:
Hernandez Settlement Administrator
c/o JND Legal Administration
P.O. Box 91306
Seattle, WA 98111

II. CLAIMANT INFORMATION

The Settlement Administrator will use this information for all communications regarding this Claim Form and the
settlement. If this information changes, you MUST notify the Settlement Administrator in writing at the address
above.
Claimant Last Name, First Name, Middle Initial

Alternative name(s) (any additional name that might also appear on your credit report)

Name of Representative (if submitting claim on behalf of the above-named Claimant)

Mailing Address – Line 1: Street Address/P.O. Box

Mailing Address – Line 2 (If Applicable): Apartment/Suite/Floor Number

City State Zip Code

American Samoa

Home Phone Number Work Phone Number Cell Phone Number

Email Address

Date of Birth (mm/dd/yyyy) SSN

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 III. CLAIM DETAILS
If you submitted a claim in the 2009 Proposed Settlement, check here:

If known, provide your Claim Number from that settlement:

Note: If you submitted a claim in the 2009 Proposed Settlement and do not wish to change your contact
information or claim a different benefit, you do not need to submit this Claim Form. All claims submitted in the
2009 Proposed Settlement and not amended will be deemed submitted in this settlement. If you are unsure
whether you submitted a claim in the 2009 Proposed Settlement or unsure whether your claim was accepted,
please complete this form.
Indicate below whether you wish to receive a Non-Monetary Award, consisting of a free file disclosure and two
free VantageScore credit scores or a Monetary Award – either a Convenience Award or an Actual Damages
Award.

Non-Monetary Award (Free File Monetary Award (Convenience Award or

Disclosure and two Free Actual Damages Award)
VantageScore Credit Scores)

If you elected to receive a Monetary Award, select ONE AND ONLY ONE of the options below:

Option 1 (Convenience Award): I cannot make the certification required for Option 2, but I wish to
receive a Convenience Award which is estimated to be, but may be more or less than, $15–20,
depending on how many people choose this Option.

Option 2 (Actual Damages Award): I hereby CERTIFY that I believe I have been damaged by an
error in my credit report regarding debts discharged in bankruptcy with respect to one or more of the
transactions listed in the next section and wish to receive an Actual Damage Award, which will be $150,
$500, or $750, depending on the transaction involved.

NOTE: If you request a Monetary Award but do not choose one of the Options above, your claim will only be
considered for a Convenience Award. If you do not return this Claim Form and supporting documentation, as
required, postmarked by November 13, 2017, and you did not submit an approved claim in the 2009 Proposed
Settlement, you will get nothing from the settlement and—unless you exercise your right to opt out of the
settlement as detailed in the Class Notice—you will lose your right to damages based on the alleged practices
that are the subject of the settlement.

IV. ACTUAL DAMAGE DETAILS

If you selected Option 2 above, you must also complete this section and provide supporting documentation.
If you selected a Non-Monetary Award or a Convenience Award, you do not need to complete this section.

A. Documentation of Harm
Indicate the type(s) of harm you believe you have suffered and provide the requested information in each case.
Note that this settlement covers credit reports issued from March 15, 2002 to May 11, 2009 (or, for California
residents in the case of TransUnion, from May 12, 2001 to May 11, 2009.) In order to qualify for an Actual
Damage Award, the information you provide must relate to this time period. You must provide this information
about the transaction so that your claim can be verified. If you do not do so, your Actual Damages Claim will be
rejected, and your claim will be converted into a Convenience Claim.

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 Month/Year
Employment I actually applied for

Name of prospective employer:

A mortgage or a housing rental I actually applied for

Name of prospective creditor:

(e.g., mortgage broker, lender, bank, housing or other mortgage creditor, landlord)
A credit card, auto loan, or other credit I actually applied
for, or payment of a discharged debt to obtain credit

Name of prospective creditor:

(e.g., credit card company, bank, credit union, department/retail store, auto dealership/lender, other)

B. SUPPORTING DOCUMENTATION
Indicate below what supporting documentation you have included with your claim. Attach only copies of
supporting documentation as these documents will not be returned to you.
All Types of Claims
Notice or letter of an Adverse Action from a prospective creditor, employer, landlord, etc.

Employment Claims
Letter/other correspondence from prospective employer or employment agency

Affidavit from prospective employer or employment agency that an employment inquiry occurred

Other: (explain)

Mortgage/Other Housing Claims

Letter/other correspondence from a bank, mortgage broker or potential housing lender

Letter/other correspondence from a landlord, apartment complex or rental agency

Affidavit from any of the above that a credit inquiry occurred

Other: (explain)

Creditor Claims
Letter/other correspondence from any prospective lender, such as a bank, credit union, department
store, or auto dealership/lender

Affidavit from any of the above that an employment inquiry occurred

Other: (explain)

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C. CERTIFICATION
I hereby certify under penalty of perjury that I have personal knowledge of all of the information I provided in this
Claim Form and that such information is true and correct to the best of my knowledge, and, additionally, that I
believe I have suffered an adverse action or other harm on or around the approximate dates I have provided, and
I believe such harm or adverse action to be a result of error(s) in my credit report(s) regarding debts discharged
in bankruptcy.

Signature of Claimant Date

If the Claimant is not the person completing this form, the following also must be provided:

Signature of Representative Date

Capacity of person signing on behalf of Claimant, if other than an individual, e.g., executor, president, trustee,
guardian, custodian, etc. (must provide evidence of authority to act on behalf of Claimant).

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 REMINDER CHECKLIST
If you are submitting an Actual Damages Claim, please sign the above
certification.

Remember to attach only copies of acceptable supporting documentation

as these documents will not be returned to you.

Please do not highlight any portion of the Claim Form or any supporting
documents.

Keep copies of the completed Claim Form and documentation for your own
records.

The Settlement Administrator will acknowledge receipt of your Claim Form

by email, within 60 days. Your claim is not deemed filed until you receive
an acknowledgement email. IF YOU DO NOT RECEIVE AN
ACKNOWLEDGEMENT EMAIL WITHIN 60 DAYS, PLEASE CALL THE
SETTLEMENT ADMINISTRATOR TOLL-FREE AT (866) 237-3432.

If your address changes in the future, or if this Claim Form was sent to an
old or incorrect address, please send the Settlement Administrator written
notification of your new address. If you change your name, please inform
the Settlement Administrator.

If you have any questions or concerns regarding your claim, please contact
the Settlement Administrator at the address below, by toll-free phone at
(866) 237-3432, by email at [email protected], or
you may visit www.BankruptcyDischargeSettlement.com. Please DO NOT
call the Defendants or their Counsel with questions regarding your
claim.
THIS CLAIM FORM AND SUPPORTING DOCUMENTATION, AS REQUIRED, MUST BE MAILED TO THE
SETTLEMENT ADMINISTRATOR BY FIRST-CLASS MAIL, POSTMARKED NO LATER THAN
NOVEMBER 13, 2017, ADDRESSED AS FOLLOWS:
Hernandez Settlement Administrator
c/o JND Legal Administration
P.O. Box 91306
Seattle, WA 98111
A Claim Form received by the Settlement Administrator shall be deemed to have been submitted when posted,
if a postmark date on or before November 13, 2017 is indicated on the envelope and it is mailed First Class,
and addressed in accordance with the above instructions. In all other cases, a Claim Form shall be deemed to
have been submitted when actually received by the Settlement Administrator.
You should be aware that it will take a significant amount of time to fully process all of the Claim Forms. Please
be patient and notify the Settlement Administrator of any change of address.

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