I have read and am familiar with the contents of the Instructions accompanying this Claim Form. I certify that the information I have set forth in the above Claim Form and
in any documents attached by me are true, correct and complete to the best of my knowledge. I certify that I or the Class Member I represent
1) paid the total amount set forth above in out-of-pocket expenditures for purchases for purchases of Lovenox® or generic enoxaparin (or bought the total number of syringes indicated)
Arizona, Arkansas, California, District of Columbia, Florida, Hawaii, Illinois, Iowa, Kansas, Maine, Massachusetts, Michigan, Minnesota, Mississippi, Missouri, Montana, Nebraska,
Nevada, New Hampshire, New Mexico, New York, North Carolina, North Dakota, Oregon, South Dakota, Tennessee, Utah, Vermont, West Virginia, and Wisconsin
during the period from September 21, 2011 through September 30, 2015;
2) did not have insurance when the payment was made;
3) purchased the Lovenox® or generic enoxaparin from a pharmacy; and
4) purchased at least some generic enoxaparin and did not only purchase branded Lovenox, as opposed to generic enoxaparin or a mix of both.
I further certify that I or the Class Member I represent did not opt out of the Class in this Action and did not purchase such Lovenox® or generic enoxaparin for purposes of resale.
In addition, I have not (or the represented Class Member has not) served as counsel, officer, director, agent, or employee of any of the Defendants, or a corporate parent, subsidiary,
affiliate, or other related entity thereof; or served as a judge or justice assigned to hear any aspect of this lawsuit.
To the extent I have been given authority to submit this Claim Form by a Class Member on its behalf, and accordingly am submitting this Claim Form in the capacity of an Authorized
Agent with authority to submit it by the Class Member identified on a separate sheet of paper submitted with this form, and to the extent I have been authorized to receive on behalf
of this Class Member(s) any and all amounts that may be allocated to it from the Settlement Fund, I certify that such authority has been properly vested in me and that I will fulfill
all duties I may owe the Class Member. If amounts from the Settlement Fund are distributed to me and a Class Member later claims that I did not have the authority to claim and/or
receive those amounts on its behalf, I and/or my employer will hold the Class, counsel for the Class, and the Notice and Claims Administrator harmless with respect to any claims made
by the Class Member.
I hereby submit to the jurisdiction of the United States District Court for the Middle District of Tennessee for all purposes connected with this Claim Form, including resolution of
disputes relating to this Claim Form. I acknowledge that any false information or representations contained herein may subject me to sanctions, including the possibility of
criminal prosecution. I agree to supplement this Claim Form by submitting documentary backup for the information provided in this form, upon request of the Notice and Claims Administrator.