Exclusion Request Form


[Case Caption]


If you want to remain a member of the class, you should notfill-in this form and are not required to do anything at this time. This form is only used if you want to exclude yourself from this case.

If you want to opt-out of the class, you must fill-in this Exclusion Request form and return it to the United State District Court, Office of the Clerk, [street address, city, state, zip] by mail postmarked no later than [month, date, year].

If you exclude yourself from the class: (1) You will not share in any recovery that might be paid claimants as a result of any settlement of this lawsuit. (2) You will not be bound by any decision in this lawsuit. (3) You may pursue any claims you have against the defendant by filing your own lawsuit.

If you have any questions regarding this case, please call class counsel at [phone], or write for information class counsel will send to you. Class counsel's address is [street address, city, state, zip]. DO NOT CALL THE CLERK OF COURT FOR INFORMATION.


I hereby certify that I believe myself to be a member of the class.

Further, I want to exclude myself from this lawsuit.


Please print legibly:

Name _______________________________________ Date ______________________

Address __________________________________ Phone _____________________

City _____________________ State ___________ Zip Code __________

Signature of Class Member _______________________________________________________

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