Enhanced Prompt: Claim Form for Class Members

You are tasked with drafting a comprehensive Claim Form for Class Members in a class action litigation matter. This document serves as the critical mechanism through which class members assert their rights to participate in a settlement or judgment, and it must balance accessibility for lay claimants with legal precision and enforceability.

Document Purpose and Context

This Claim Form must enable eligible class members to submit claims for compensation or other relief while protecting the integrity of the settlement process. The form should be written in plain language accessible to non-lawyers while maintaining all necessary legal formalities. It must comply with Federal Rule of Civil Procedure 23 (or applicable state class action rules), court orders governing the settlement, and any specific requirements established by the settlement agreement. Consider that this document will be reviewed by the settlement administrator, may be subject to challenge by opposing counsel, and could be scrutinized by the court if disputes arise regarding claim validity.

Header and Case Identification Section

Begin with a clear, prominent title identifying this as an "Official Claim Form" for the specific class action. Include the complete case caption with the full names of all named plaintiffs and defendants, the court name and jurisdiction, and the complete case number. Provide the settlement administrator's complete contact information, including mailing address, email, phone number, and website if applicable. Include the claim submission deadline prominently, using bold or larger font, and specify the postmark rule or other timing requirements. Add a brief introductory paragraph explaining the purpose of the form and who is eligible to submit it, written in plain language that a layperson can understand. Reference the settlement agreement date and any court order approving the settlement, providing sufficient detail for class members to verify they are completing the correct form for their case.

Claimant Information and Identification

Design this section to collect all information necessary to verify class membership and process payment or other relief. Request the claimant's full legal name as it appeared during the class period, current legal name if different, complete current mailing address, email address, and telephone number. Include fields for alternative contact information to ensure the claimant can be reached if questions arise. If the class definition includes specific criteria (such as purchase dates, account numbers, or employment periods), create clear fields for this information with instructions explaining why it is needed. For claims involving deceased class members, estates, or legal representatives, include appropriate fields for executor/administrator information and require documentation of authority. Consider privacy concerns by including a statement about how personal information will be used and protected, and ensure compliance with applicable privacy laws. If the settlement involves minors or legally incapacitated persons, provide clear instructions for guardians or representatives and specify required supporting documentation.

Claim Details and Supporting Documentation

This section must elicit sufficient information to evaluate claim validity and calculate appropriate compensation under the settlement terms. Clearly explain the types of claims covered by the settlement and provide checkboxes or fields for claimants to identify which category applies to them. For each claim type, specify the time period during which the relevant conduct or transaction must have occurred. Create fields for claimants to provide specific details such as:

• Dates of purchase, transaction, or relevant events
• Amounts paid or damages incurred
• Account numbers, transaction identifiers, or other reference information
• Description of harm suffered or basis for the claim
• Calculation of claimed amount if the settlement requires claimants to compute their own recovery

Provide clear instructions about supporting documentation, specifying whether documents must be submitted with the claim form or retained for possible later verification. List acceptable forms of documentation (receipts, account statements, contracts, correspondence, etc.) and explain whether copies or originals are required. If the settlement allows claims without documentation under certain circumstances, clearly explain the threshold amounts or conditions. Include a statement that submission of false information may result in claim denial, civil penalties, or criminal prosecution.

Certification, Attestation, and Release Provisions

Draft a certification section that requires the claimant to affirm, under penalty of perjury, that all information provided is true, accurate, and complete to the best of their knowledge. The certification should specifically state that the claimant meets the class definition, has not previously released these claims, and has not received compensation for these claims through other means. Include language confirming that the claimant understands they are bound by the settlement terms and any court orders or judgments entered in the case.

Incorporate a comprehensive release clause that clearly explains what claims the claimant is releasing by submitting this form. The release should identify the released parties (defendants, related entities, officers, directors, etc.) and describe the scope of released claims with sufficient specificity to be enforceable while remaining comprehensible to lay readers. If the release includes unknown claims, include the required statutory language (such as California Civil Code Section 1542 waiver language if applicable). Explain the consequences of submitting the claim form, including that the claimant will be bound by the settlement and any judgment, will give up the right to sue separately, and will be bound by any appeals or challenges to the settlement. Use clear headings and consider a separate acknowledgment checkbox for the release to ensure claimants understand this critical provision.

Signature Block and Submission Instructions

Create a signature section that includes a line for the claimant's handwritten or electronic signature (as appropriate), printed name, title or relationship to the claim if applicable, and date of signature. If the form may be submitted electronically, include language confirming that electronic signatures are acceptable and legally binding. For claims submitted on behalf of entities, estates, or by legal representatives, require identification of the signatory's authority and relationship to the claimant.

Provide comprehensive submission instructions that specify all acceptable methods of filing (mail, email, online portal, etc.) and the complete address or URL for each method. Clearly state the submission deadline using both a specific date and time (including time zone) and explain whether the postmark date, receipt date, or upload date controls. Include instructions for obtaining confirmation of receipt and what to do if the claimant does not receive confirmation within a specified timeframe. Provide contact information for the settlement administrator and specify the hours when assistance is available. Include a statement about what happens after submission, including the approximate timeline for claim review, when claimants can expect to receive notice of claim approval or denial, and the process for challenging a claim denial. Add a reminder to retain copies of the completed claim form and all supporting documentation for the claimant's records.

Final Document Assembly

Ensure the completed Claim Form is formatted professionally with consistent fonts, clear section headings, and adequate white space for readability. Number all pages and include the case name and number in a header or footer on each page. If the form exceeds two pages, consider adding a table of contents or checklist on the first page. Include any required legal notices, such as statements that submission of a claim form does not guarantee payment, that the settlement is subject to court approval, or that attorneys' fees will be deducted from the settlement fund. Verify that all language complies with court orders, the settlement agreement, and applicable rules of civil procedure. The final document should be available in formats accessible to individuals with disabilities and should be translatable if the class includes non-English speakers.