Claim Form

Claimant Information

Please provide contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form.

First Name

Last Name

Business Name

Address 1

Address 2

City

State

Zip Code

Phone

Email

Class Confirmation

Please provide the street address where you received electric service between April 2, 2019, and April 30, 2025.*

Address 1

Address 2

City

State

Zip Code

Note: If you lived in more than one location between April 2, 2019, and April 30, 2025.that received electrical service, provide the address where you lived the longest.

Please enter the date range when you paid for electricity for the address listed above.*

From:

01/01/2000 - 04/30/2025

To:

04/02/2019 - Today

Was your billing address different from your street address at the time you received electric service at the address above?*

YesNo

Payment Election

IMPORTANT NOTES:

For E-Mastercard, PayPal, Venmo, Zelle payments, if there are any discrepancies, if the account is no longer active, or if the Administrator deems that payment cannot or should not be made based on the provided information, the Administrator will either contact you for clarification or be authorized to default to a Check payment.
If domestic or international payment limits apply to your payment, you may receive more than one transmission or you may default to a Check payment.
Venmo and Zelle payments cannot be made to accounts outside of the United States.
Payments by Check will be made out to the Name on this Form and mailed to the address on this Form.

Attestation & Signature

By submitting this claim form, I certify that under the penalty of perjury the above statements are true and correct to the best of my knowledge.

Signature

Date