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`EXHIBIT D
`
`
`
`Case 2:12-md-02311-SFC-RSW ECF No. 2205-6, PageID.39981 Filed 04/25/22 Page 2 of 6
`Auto Parts Settlements
`P.O. Box 10163
`Dublin, OH 43017-3163
`Toll-Free: 1-877-940-5043
`
`*P-YAA-POC/1*
`
`AUTO PARTS CLASS CLAIM FORM
`TO SUBMIT A CLAIM FOR PAYMENT:
`
`1.) Complete all information below.
`2.) You must provide your name and contact information.
`3.) All information is subject to verification for accuracy by the Settlement Administrator.
`
`4.) You must confirm that the information you provide is true and correct by signing the Claim Form. Unsigned
`Claim Forms will be denied.
`
`5.) Submit the completed Claim Form to the Settlement Administrator listed below. You may go to
`www.AutoPartsClass.com to submit your claim online, or you may transmit the Claim Form to:
`
`Auto Parts Settlements
`P.O. Box 10163
`Dublin, OH 43017-3163
`
`6.) If your contact information changes, please contact the Settlement Administrator at the address above to
`update your contact information.
`
`No documentation is required at this time, but please hold on to any documents that you have.
`The Settlement Administrator will contact you if additional information is needed.
`
`QUESTIONS? VISIT WWW.AUTOPARTSCLASS.COM OR CALL TOLL-FREE 1-877-940-5043
`1
`
`CLAIMANT ID:10022297
`
`
`
`Case 2:12-md-02311-SFC-RSW ECF No. 2205-6, PageID.39982 Filed 04/25/22 Page 3 of 6
`
`SECTION I: CLAIMANT CONTACT INFORMATION
`
`*P-YAA-POC/2*
`Name: bbbbbbbbbbbbbbbbbbbbbbbbbbbb
`Address: bbbbbbbbbbbbbbbbbbbbbbbbbbbb
`bbbbbbbbbbbbbbbbbbbbbbbbbbbb
`bbbbbbbbbbbbbbbbbbbbbbbbbbbb
`Telephone Number: (www) www - wwww
`Email Address: wwwwwwwwwwwwwwwwwwwww
`
`City:
`
`State:
`
`Zip:
`
`Are you filing a claim for a business? Yes No
`
`SECTION II: PURCHASE/LEASE CLAIMS SECTION
`Are you making a claim for the purchase or lease of a new vehicle? Yes No
`How many vehicles are you claiming?
`
`
`wwgggg
`
`For each vehicle for which you are making a claim, please complete a row in the table below and provide all of the
`requested information (attach additional sheets if needed). You can submit a claim even if you do not know your
`VIN.
`Vehicle
`Year
`
`State of Residence or
`Principal Place of
`Business at Time of
`Purchase or Lease
`
`Estimated
`Date of
`Purchase or
`Lease
`
`Purchase
`or
`Lease?
`
`Vehicle
`Make
`
`Vehicle
`Model
`
`VIN
`(Vehicle Identification
`Number)
`
`SEE CLAIM FORM ADDENDUMS
`
`To determine if your vehicle is included in the Settlements, please visit www.AutoPartsClass.com or
`contact the toll-free number below. Please note that additional vehicles may be identified at a later date.
`If you need additional space to record more entries, you may attach additional sheets. Please be sure to include all
`of the information requested in the table above on any additional sheets that you attach.
`
`QUESTIONS? VISIT WWW.AUTOPARTSCLASS.COM OR CALL TOLL-FREE 1-877-940-5043
`To view GCG's Privacy Notice, please visit http://www.gcginc.com/pages/privacy-policy.php
`2
`
`CLAIMANT ID:10022297
`
`
`
`CLAIMANT ID:10022297
`Case 2:12-md-02311-SFC-RSW ECF No. 2205-6, PageID.39983 Filed 04/25/22 Page 4 of 6
`SECTION III: REPLACEMENT PART CLAIMS SECTION
`
`Are you making a claim for the purchase of an eligible vehicle replacement part? Yes No
`How many replacement parts are you claiming?
`
`
`wwwwgg
`
`For each replacement part for which you are making a claim, please complete a row in the table below and provide
`all of the requested information (attach additional sheets if needed):
`Replacement
`State of Residence or
`Replacement
`Part Purchased
`Principal Place of
`Part Purchased
`(See List on Website)
`Business at Time of
`(See List on Website)
`Purchase
`
`Manufacturer of
`Replacement Part
`
`Estimated
`Date of
`Purchase
`
`SEE CLAIM FORM PARTS ADDENDUMS
`
`For a list of the vehicle parts included in the Settlements, please consult the Notice or visit
`www.AutoPartsClass.com.
`If you need additional space to record more entries, you may attach additional sheets. Please be sure to include all
`of the information requested in the table above on any additional sheets that you attach.
`
`I confirm the information provided above is true and correct.
`
`SIGNED:____________________________________________
`
`DATE:_____________________________
`
`QUESTIONS? VISIT WWW.AUTOPARTSCLASS.COM OR CALL TOLL-FREE 1-877-940-5043
`To view GCG's Privacy Notice, please visit http://www.gcginc.com/pages/privacy-policy.php
`3
`
`CLAIMANT ID:10022297
`
`
`
`Case 2:12-md-02311-SFC-RSW ECF No. 2205-6, PageID.39984 Filed 04/25/22 Page 5 of 6
`
`CLAIMANT ID:10022297
`
`
`
`Case 2:12-md-02311-SFC-RSW ECF No. 2205-6, PageID.39985 Filed 04/25/22 Page 6 of 6
`
`CLAIMANT ID:10022297
`
`
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