Fillable V4 M2c Claim 082919 Final Web

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V4 M2c Claim 082919 Final Web

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1
*M2CWONE*
Macy’s Cyber Attack
Settlement Administrator
P.O. Box 43499
Providence, RI 02940-3499
M2C
Anna Carroll v. Macy’s Inc. et al.
UNITED STATES DISTRICT COURT, NORTHERN DISTRICT OF ALABAMA
Case No. 2:18-cv-01060-RDP (N.D. Ala.)
Claim Form
FOR CLAIMS
PROCESSING
ONLY
OB CB
DOC
LC
REV
RED
A
B
Must Be Postmarked No Later Than April 6, 2020
SETTLEMENT OVERVIEW
Documented Losses and Time
If you have documentation establishing that you experienced out-of-pocket losses as a result of the Macy’s Cyber Attack
(as dened in the Settlement) or spent time dealing with the repercussions of the Cyber Attack, you can make a claim
for reimbursement up to $1,500.00, including up to 5 hours of documented time at $15.00 per hour. You must submit
supporting documentation for this claim.
Self-Certifying Time
If you do not have documentation, you will still be eligible to self-certify your time spent dealing with the
repercussions of the Cyber Attack at $15.00 per hour for up to 2 hours.
The total amount for both Documented Losses and Time and Self-Certifying Time is capped at $1,530.00 per
claimant.
DOCUMENTED CLAIMS FOR OUT-OF-POCKET LOSSES OR TIME SPENT DEALING WITH THE
REPERCUSSIONS OF THE CYBER ATTACK
1. Do you have documents supporting that you experienced out-of-pocket losses as a result of the Cyber Attack
or spent time dealing with the repercussions of the Cyber Attack? You may submit a claim, with supporting
documentation, for up to $1,500.00 in out-of-pocket losses or time spent dealing with the repercussions of the
Cyber Attack.
Yes (proceed to the chart below)
No (skip to Question No. 2)
First Name M.I. Last Name
Primary Address
Primary Address Continued
City State Zip Code
Foreign Province Foreign Postal Code Foreign Country Name/Abbreviation
CLAIMANT INFORMATION
2
*M2CWTWO*
Loss Type (ll all that apply)
Costs and expenses spent addressing identity theft or fraud as a result of the Cyber Attack.
Date of Loss:
M M D D Y Y Y Y
Amount of Loss:
$
.
Description of Supporting Documentation (identify what you are attaching and why)
Examples: Receipt or account statement reecting fuel costs for driving to bank or ling police report; receipt for hiring service to
assist you in addressing identity theft
Preventative costs including purchasing credit monitoring, placing security freezes on credit reports, or requesting copies of credit
reports for review as a result the Cyber Attack.
Date of Loss:
M M D D Y Y Y Y
Amount of Loss:
$
.
Description of Supporting Documentation (identify what you are attaching and why)
Examples: Receipts or account statements reecting purchases made for credit monitoring services or to place a credit freeze
Documented time spent dealing with the repercussions of the Cyber Attack.
Date of Loss:
M M D D Y Y Y Y
Number of Hours Spent (max = 5 hours)
Description of Supporting Documentation (identify what you are attaching and why)
Examples: Phone bill reecting time spent on phone with bank. You may make a claim for up to 5 hours of documented time at $15.00 per hour
Other documented losses incurred as a result of the Cyber Attack that were not reimbursed (provide detailed description).
Date of Loss:
M M D D Y Y Y Y
Amount of Loss:
$
.
Please provide detailed description and supporting documentation
SELF-CERTIFIED CLAIMS FOR TIME
2. Did you spend time or additional time other than what is documented above dealing with the repercussions of
the Cyber Attack? You may make a claim for up to 2 hours of undocumented time at $15.00 per hour.
Yes (please ll out the statement below)
No (skip to the attestation and signature)
I spent (up to two) hours dealing with the repercussions of the Cyber Attack to be reimbursed at a rate of $15.00 per hour.
ATTESTATION AND SIGNATURE: I do hereby swear (or arm), under penalty of perjury, that the information
provided above is true and accurate to the best of my knowledge and that the compensation I am claiming is based
on losses I reasonably believe to the best of my knowledge were the result of the Cyber Attack.
Signature: Dated (mm/dd/yyyy):
Print Name:
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Completed 18 July 2020

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