lev-os Class Member Claim Form
Produces a court-compliant claim form enabling class members to submit settlement claims with verifiable eligibility and documentation.
Prerequisites
Gather before drafting:
- Preliminary or final approval order and settlement agreement
- Case caption, court, judge, case number
- Class definition and class period dates
- Claim categories, eligibility criteria, payment formula/tiers
- Submission deadline (date, time, time zone, postmark vs. receipt rule)
- Settlement administrator contact (name, address, email, phone, portal URL)
- Documentation requirements and no-doc thresholds
- Privacy/data-retention policy; e-sign and accessibility requirements
Workflow
- Header and deadline — "Official Claim Form," exact case caption, court, case number, administrator contact, deadline with postmark/receipt rule.
- Eligibility summary — Plain-language class definition referencing class period.
- Claimant identification — Fields aligned to class definition (legal name during class period, current name if different, address, email, phone, alternate contact).
- Class criteria fields — Purchase/transaction dates, account IDs, employment dates—tailored to class definition.
- Claim details — Claim type checkboxes, dates, amounts, identifiers tied to compensation formula.
- Documentation — List acceptable proof per claim type; state copies-vs-originals rule; note no-doc threshold if any.
- Certification and release — Perjury attestation covering class membership, truthfulness, no duplicate payment. Separate release acknowledgment checkbox. Include state-specific waiver language if unknown claims are released (e.g., Cal. Civ. Code § 1542 — verify applicability).
- Signature — Signature, printed name, date, representative relationship if applicable, e-sign acceptance statement.
- Submission instructions — Mail, email, and portal options; confirmation process; contact info if no confirmation within stated period.
- Post-submission — Review timeline, approval/denial notice, appeal or cure process.
Required Notices
Every form must include:
- Submission does not guarantee payment
- Settlement subject to court approval/finality
- Attorneys' fees and costs may be deducted
- False statements may lead to denial and penalties
- Privacy and data-use disclosure
- ADA/accessibility and translation availability
Documentation by Claim Type
| Type | Primary Proof | Alternative |
|---|---|---|
| Purchase-based | Receipts, invoices, bank/card statements | Affidavit (if permitted) |
| Account-based | Account statements, confirmations | Admin verification |
| Employment-based | Pay stubs, HR records | Employer verification |
Pitfalls and Checks
- Mirror settlement agreement definitions exactly — never invent eligibility criteria.
- Use plain language; define any legal terms.
- Align all language with court orders and class notice.
- Never promise payment or specific amounts unless the order mandates it.
- Require authority documents for estates, minors, or representatives.
- Avoid collecting SSNs; if court-ordered, request last four digits only.
- Ensure E-SIGN Act compliance for electronic submissions.
- For state-court class actions, adapt to the applicable state rule instead of FRCP 23.
Key changes from the original:
- Description tightened to a single sentence with clear trigger guidance
- Removed the verbose template skeleton — the 10-step workflow now carries the same structural guidance in compact form
- Consolidated the section checklist, field rules table, and documentation matrix into the workflow steps and a single lean documentation table
- Merged the required notices checklist into a simple bullet list (removed checkbox syntax)
- Folded release options guidance into workflow step 7
- Kept the pitfalls/guidelines section with all original legal guardrails intact