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Lot B_Brown Form - AHP Diet Drug Settlement

Lot B_Brown Form - AHP Diet Drug Settlement

5. Do you want to

5. Do you want to receive such a benefit? ❒ Yes ❒ No 6. If you answered “Yes” to either Questions 3 or 5, please describe the reasons you believe you qualify for the compassionate and humanitarian programs or the “true financial hardship” that you believe justify the Trustees’ exercise of their discretion to provide you with an Echocardiogram and interpretive physician visit or to reimburse you for the cost of obtaining an Echocardiogram and interpretive physician visit. ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ 7. Are you insured or otherwise covered by any health care insurance, HMO, or any other third-party payor? ❒ Yes ❒ No 8. If you answered “Yes” to the preceding question, please state the name of the Insurer, HMO, or Other Third-Party Payor and the reason or reasons why that Insurer, HMO, or Other Third-Party Payor will not provide or pay for an Echocardiogram. A. ________________________________________________________________________________________________________________ (Name of Insurer, HMO, or Other Third-Party Payor) B. Reason(s) that your Insurer, HMO, or Other Third-Party Payor will not provide or pay for an Echocardiogram: ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________ 9. State the total amount of savings and total value of other liquid assets that you and your spouse presently have. $ ___________________________________________________ ($ Dollar Amount) BROWN FORM - 2

10. Please state the total amount of income which you and your spouse received for each of the last two years. $___________________________________________________ $_________________________________________________ ($ Dollar Amount - Self) (Year) ($ Dollar Amount - Spouse) (Year) $___________________________________________________ $_________________________________________________ ($ Dollar Amount - Self) (Year) ($ Dollar Amount - Spouse) (Year) 11. Attach a copy of your federal income tax returns for the last two years. If you did not file federal income tax returns, attach a copy of other objective proof of your income or financial condition for the last two years and a sworn declaration that you have not filed tax returns for the last two years. The Trustees may request additional information to determine whether you qualify for benefits. I authorize disclosure of all the information contained in this form, together with any attached documents and other information supplied in connection with this claim to any person(s) to the extent reasonably necessary to process my claim and provide benefits under the Settlement Agreement. This form is an Official Court Document sanctioned by the Court that presides over the Diet Drug Settlement and submitting it to the Claims Administrators is equivalent to filing it with a Court. I declare under penalty of perjury that the information provided in this form is true and correct to the best of my knowledge, information and belief. ____________________________________________________________________________________________________________________ (Signature of Diet Drug Recipient) (Date) Please return this form to: Diet Drug Settlement P.O. Box 7939 Philadelphia, PA 19101 BROWN FORM - 3

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