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PART IV - SUBMISSION TO JURISDICTION OF THE DISTRICT COURT By signing below, you are verifying that: You have provided genuine documentation to support your claim and agree to provide additional information to Interim DPP Lead Counsel or the Settlement Administrator if necessary; 2. You have not assigned or transferred (or purported to assign or transfer) or settled for the same purchases or submitted any other claim for the same purchases of Alum and have not authorized any other person or entity to do so, and know of no other person or entity having done so on your behalf; 3. The information provided in this Claim Form is accurate and complete; and 4. You agree to submit to the jurisdiction of the United States District Court for the District of New Jersey, where this Action is pending, for purposes of resolving any issues related to or arising from your claim. PART V - CERTIFICATION I (We) certify that I am (we are) NOT subject to backup withholding under the provisions of Section 3406 (a)(1)(c) of the Internal Revenue Code because: (a) I am (We are) exempt from backup withholding, or (b) I (We) have not been notified by the IRS that I am (we are) subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me (us) that I am (we are) no longer subject to backup withholding. NOTE: If you have been notified by the IRS that you are subject to backup withholding, completely fill in this bubble: UNDER THE PENALTIES OF PERJURY, I (WE) CERTIFY THAT ALL OF THE INFORMATION PROVIDED BY ME (US) ON THIS CLAIM FORM IS TRUE, CORRECT, AND COMPLETE, AND THAT THE DOCUMENTS SUBMITTED HEREWITH ARE TRUE AND CORRECT COPIES OF WHAT THEY PURPORT TO BE. Signature of claimant Print your name here Company Name Capacity of Person Signing Date YOU MUST COMPLETE AND RETURN THIS PAGE OF THE CLAIM FORM