Shaheen v. City of Belmont

NORTH CAROLINA GENERAL COURT OF JUSTICE, SUPERIOR COURT DIVISION

Case No. 17-CVS-3924

File a Claim


INSTRUCTIONS FOR COMPLETING CLAIM FORM


If you are filing a claim for multiple addresses, please fill out the Claim Form Addendum, and submit it with this Claim Form.

If you believe you are a member of the Settlement Class who paid Impact Fees and/or System Development Fees to the City on or between October 10, 2014 and June 30, 2018, and are seeking relief under this Settlement, then you must complete and return the enclosed Claim Form.

Electronic Claim Form submissions must be received by September 17, 2019.

Please read the full Notice before completing your Claim Form. If you have questions about this Claim Form, please contact the Settlement Administrator via email at info@BelmontSettlement.com, or toll-free at 1-844-336-127.

ALL CLAIMS ARE SUBJECT TO VERIFICATION

PLEASE KEEP A COPY OF YOUR COMPLETED CLAIM FORM FOR YOUR RECORDS


SECTION A: NAME AND CONTACT INFORMATION


Provide your name and contact information below. It is your responsibility to notify the Settlement Administrator of any changes to your contact information after the submission of your Claim Form.

* Required









Yes
No

SECTION B: INFORMATION ABOUT FEES PAID DURING THE CLASS PERIOD



Yes
No

SECTION C: CERTIFICATION STATEMENT FOR ENTIRE CLAIM FORM





Type your name here




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