UPenn Covid Refund Settlement

INFORMATION FORM

For the Class Members who will not be Continuing Penn Students, such Settlement Class Members may complete the Information Form to: (a) provide an updated address for sending a check and/or updated contact information; or (b) elect to receive the Settlement Benefit by Venmo or PayPal instead of a paper check. Please only complete the Information Form if you are not a Continuing Penn Student.

You may also notify the Settlement Administrator by emailing to info@UPennCovidRefundSettlement.com, calling toll-free 1-877-388-1717, or by writing to the Settlement Administrator at University Covid Refund Settlement, c/o A.B. Data, Ltd., P.O. Box 170500, Milwaukee, WI 53217.

Important: If you are a Continuing Penn Student, your Settlement Benefit will be credited to your student account; you will not be eligible to receive the Settlement Benefit by Venmo, PayPal, or check.

SETTLEMENT CLASS MEMBER INFORMATION

Full Name: *

Mailing Address (Street, PO Box, Suite or Office Number): *

City: *

State: *

Zip: *

*A valid mailing address must be provided to receive a check. If the address you have on file changes, it is your responsibility to provide accurate contact information to the Settlement Administrator to receive a payment.

ADDITIONAL INFORMATION

Notice ID – Your Notice ID is located on the upper right hand corner on the Settlement Notice that was emailed or mailed to you. If you do not have a Notice ID, please contact the Settlement Administrator by emailing to info@UPennCovidRefundSettlement.com, calling toll-free 1-877-388-1717, for assistance on any changes you would like made to your record or payment option.

Notice ID: *

Email Address:

Telephone Number:

* A valid email address must be provided to receive digital payment. If the email address you have on file changes or becomes invalid for any reason, it is your responsibility to provide accurate contact information to the Settlement Administrator to receive a payment.

If you would like to request digital payment instead of a paper check, please check the box below.

I request to have my Settlement Benefit be in the form of a digital payment.

Claimant Signature: *