If you received a personalized notice in the mail or via email with a Notice ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

If you did not receive a personalized Notice in the mail or via email, click below to complete a Claim Form.

If you were notified by Afni, Inc. (“Afni”) that your Personal Identifiable Information (“PII”) including your name, address, date of birth, social security number, and/or financial account information was exposed as a result of the cyberattack on Afni on or about June 7, 2021 (“Data Incident”), you are a member of the Settlement Class and are eligible to complete this Claim Form to request two years of identity protection and credit monitoring service free of charge, compensation for up to 4 hours of lost time at a rate of $25.00 per hour, and/or compensation for other unreimbursed losses, up to a total of $5,000 (“Unreimbursed Losses”). As an alternative to making a claim for Unreimbursed Losses, Lost Time, or Credit Monitoring, you may elect to receive an Alternative Cash Payment (estimated to be $60), which will be determined based on the amount remaining in the Settlement Fund after the amounts in the Settlement Fund have been distributed in accordance with the Settlement Agreement.

Please read the claim form carefully and answer all questions. Failure to provide required information could result in a denial of your claim.

I. CLASS MEMBER NAME AND CONTACT INFORMATION

Provide your name and contact information below. You must notify the Claims Administrator if your contact information changes after you submit this form.

* Required Fields

II. PROOF OF CLASS MEMBERSHIP
III. ALTERNATIVE CASH PAYMENT
IV. IDENTITY THEFT PROTECTION
V. COMPENSATION FOR LOST TIME

All members of the Settlement Class, who did not select the alternative cash payment above, and who have spent time dealing with the Data Incident may claim up to four (4) hours for lost time at a rate of $25.00 per hour. Any payment for lost time is included in the $5,000.00 cap per Settlement Class member. No documentation is required.

VI. UNREIMBURSED LOSSES

All members of the Settlement Class, who did not select the alternative cash payment above, who submit a Valid Claim using this Claim Form are eligible for reimbursement of the following documented out-of-pocket expenses, not to exceed $5,000.00 per member of the Settlement Class, that were incurred as a result of the Data Incident:

Cost Type
(Fill all that apply)		 Approximate Date of Loss Amount of Loss
Examples of Supporting Documentation: Phone bills, gas receipts, postage receipts; detailed list of locations to which you traveled (i.e., police station, IRS office), indication of why you traveled there (i.e., police report or letter from IRS re: falsified tax return) and number of miles you traveled.
Examples of Supporting Documentation: Receipts or account statements reflecting purchases made for Credit Monitoring or Identity Theft Insurance Services.
Examples of Supporting Documentation: Receipts or account statements reflecting purchases made for Credit Monitoring or Identity Theft Insurance Services.
VII. UPLOAD SUPPORTING DOCUMENTATION

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected.

Please confirm in the grid below that your file has been successfully uploaded.

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    VIII. PAYMENT SELECTION

    Please select one of the following payment options, which will be used should you be eligible to receive a settlement payment:

    You have successfully requested a payment. Click here if you would like to choose a different payment method.

    IX. ATTESTATION & SIGNATURE

    I swear and affirm under the laws of my state that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below.

    Your Claim Form has been submitted successfully.

    Please print this page for your records.

    Your Claim Details
    Submitted Claim ID:
    Confirmation Code:
    You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
    CLAIM INFORMATION
    First Name
    Last Name
    Street Address
    Street Address 2
    City
    State
    Province
    Zip Code
    Postal Code
    Country
    Email Address
    Telephone Number
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Info@AfniDataIncidentSettlement.com

    Click here to edit your Claim.

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