SHEILA GUIDRY VERSUS DOW CHEMICAL COMPANY AND THE STATE OF LOUISIANA THROUGH THE DEPARTMENT OF ENVIRONMENTAL QUALITY
REQUEST FOR CLAIM FORMS TO DETERMINE CLASS SIZE AND TO REQUEST SWORN CLAIM FORMS FROM CLASS MEMBERS:
First Name *
Last Name *
Current Home Address: Number/Street *
Apt. Number
City, State, Zip *
Email Address: (if none put none) *
ADDRESS AT THE TIME OF THE INCIDENT (4:30 am on July 7, 2009, until 3:30 pm on July 8, 2009) (IF Same as Above Put Same)
Number/Street *
Apt. Number
City, State, Zip *
Please provide the following personal information:
DATE OF BIRTH *
DRIVER’S LICENSE NUMBER: *
STATE: *
IF NO DRIVERS’ LICENSE, THEN STATE ISSUED ID# *
SOCIAL SECURITY NUMBER (FULL 9 DIGIT) : *
CELL NUMBER: By Providing this information you agree to receive text messages from the Berniard Law Firm concerning updates on this case. *
HOME PHONE NUMBER:
GENDER:
Clear selection
II. SYMPTOMS EXPERIENCED
Were you located at the address listed above as “Address at the Time of the Incident during some time period between 4:30 am on July 7, 2009, until 3:30 pm on July 8, 2009?
Clear selection
If you answered Yes, then answer the questions below. If No, please do not submit a claim.
A. Check any and all symptoms that you experienced as a result of exposure to Ethyl Acrylate during that time: *
Required
IV. REPRESENTATIVE CAPACITY
If you are filling out this claim form for someone else (such as a disabled or deceased person), please state your relationship to that person AND provide documentation that you believe supports your right to file a claim on behalf of that person (such documentation might include death certificate, succession documents or power of attorney or joint title to a residence): Relationship to Claimant:
NOTE: If you have your own claim, you should fill out a separate form for yourself and for the person you claim to represent.
V. CERTIFICATION
I, certify as follows: That I am the Claimant or Legal Representative of the Claimant in the attached Proof of Claim including general claimant information and attachments; That all information provided herein is true and correct based on my personal knowledge, and I certify and declare under penalty of perjury (including pursuant to Louisiana Revised Statute 14:123) that the information provided in this Proof of Claim Form is true and accurate based on my personal knowledge; That supporting documents attached to or submitted in connection with my claim and the information contained therein are true, accurate, and complete based upon my personal knowledge, and I understand that the information provided in this Proof of Claim form may be used as evidence if a dispute arises as to my claim.
Signature: Type Name Below *
Date: *
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