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23 -Aug -2017 08:09 08-22-2017 194238EST Fax PROOF OF CLAIM Mill IlIlIlIHhll III i1111111111 111 1111111 12758275 JWD Automotive, lnc. v. DJM Advisory Group, LLC, Banner L'fe insurance Company and William Penn Life Insurance Company of New York, Casa No. 2:15-cv-00793 Fax Numbor:772-770-5334 You Must Complete This Form to Claim a Share of the Settlement Fund; 1. You Must Provide Your Contact Information. Name: Company: Address: City/State/Zip Code: Phone: Email: Fax Number(s): gist all numbers from Deoember21, 2011 to present. You may attach a separate sheet.] 2. You Must Verify Ownership of the Fax Numbar(s) Listed in #1 above: (a) "The fax number(s) identified above or attached to this Proof of Claim was/were: 1. Capable of receiving faxes, and 2. Mine or my company's at some point from December 21, 2011 through the present," X (Sign your name here) OR (b) 'The fax number(s) identified in No. 1 above or attached to this Proof of Claim was not/were not: 1. Capable of receiving faxes from December 21,2011 through the present, and/or 2. Mine or my company's at some point from December 21, 2011 through the present". Explain when you obtained the fax number(s) identified in No. 1 above or attached to this Proof of Claim: X (Sign your name here) 3. You Must Return this Claim Form by October 21, 2017: a. Fax this Claim Form to: OR b. Mail this Claim Form to: 877-704-7733 JWD v. DJM Class-Settlement.com PO Box 9009 Hicksville, NY 11802-9009 OR c. Submit this claim form electronically at: www.class-settlement.com p.3 Usemame:12758275 Password:copflyant 4. Attach Copies of Facsimiles (Optional): If you have retained copies of any faxes you believe to be advertisements sent by or on behalf of the Defendants, you should attach copies of all faxes received to this form. If you do not attach any faxes, your recovery under the Settlement will be limited to $500 per fax number, which may be reduced pro rata if the Settlement Fund is exhausted. P206