Deficiency

Provide Your Contact Information:

First Name *

M.I.

Last Name *

Street Address *

City *

State *

Zip Code *

Email Address *

Phone Number *

* Required Fields

Additional Information:

Amount Requested*

Documentary proof must be submitted to support your claim amount.

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.

Select File for Upload: *

File Description:

File List: No Files Selected

Fill Out and Sign the Following Attestation:

I declare under penalty of perjury that:

The form was submitted to the Internal Revenue Service;*

The economic loss I have claimed on this form is related to the Data Breach; and*

The total amount claimed has not been reimbursed by IDX or any other third party.*

Signature *

Date

Goetz v. Benefit Recovery Specialists, Inc.

Case No. 20 CV 550

Walworth County Wisconsin Circuit Court

DEFICIENCY

The deadline for submitting this proof of claim form is July 29, 2022

Your Claim Form has been submitted successfully.

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
Middle Initial
Last Name
Street Address
City
State
Zip Code
Email Address
Phone Number