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

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

IN ORDER TO BE VALID, THIS CLAIM FORM MUST BE SUBMITTED ONLINE NO LATER THAN NOVEMBER 24, 2022.

ATTENTION: Use this Claim Form to make a claim for Out-of-Pocket Expenses and/or Extraordinary Losses, including Time Spent that are fairly traceable to a data security incident potentially affecting the personal information of individuals participating in the CSI Financial Services LLC dba ClearBalance (together “Clear Balance”) loan program (the “Data Security Incident”). The Data Security Incident occurred between March 8, 2021 and April 26, 2021 and potentially exposed the Personal Identifying Information (“PII”) of ClearBalance loan recipients. You should also use this Claim Form to make a claim for California Cash Payment if you had a California address on file with ClearBalance at the time of the Data Security Incident. In sum, you can use this claim form to make a claim for any or all of the following, if they apply to you: (1) Out-of-Pocket Expenses, (2) Extraordinary Losses, (3) Time Spent, (4) California Cash Payment.

I. Instructions for Completing the Claim Form

To submit a Claim, you must have been identified as a potential Settlement Class Member and received E-Mailed or mailed Notice of this Settlement with a unique Claim Number. If you believe you are a Class Member and did not receive a Notice via email or U.S. Mail, you may contact the Settlement Administrator for assistance at 1-844-999-2066.

Carefully read the instructions below, and the full Notice before filling out your Claim Form.

II. Class Member Contact Information

The Settlement Administrator will use this information for all communications regarding this Claim Form. If this information changes prior to distribution of the Settlement benefits you must notify the Settlement Administrator.

* Required Fields

III. Make a Claim for a California Cash Payment ($100)

If you had a California address on file in ClearBalance’s business records at the time of the Data Security Incident and received notice of the Data Security Incident you may be eligible to submit a Claim Form to receive a cash payment of $100.00 under the Settlement. Only Settlement Class Members who had a California address on file in ClearBalance’s business records at the time of the Data Security Incident will be eligible for this California Cash Payment. To be eligible for this relief you MUST submit a Claim Form and complete Section II above.

IV. Claim for Reimbursement of Out-of-Pocket Expenses & Extraordinary Losses

If you suffered documented financial losses that are fairly traceable to the Data Security Incident you may be eligible to receive compensation.

You must submit proof of losses and the dollar amount of those losses.

Out-of-Pocket Expenses may include, without limitation: (1) costs incurred on or after March 8, 2021, associated with accessing or freezing/unfreezing credit reports with any credit reporting agency; (2) other miscellaneous expenses incurred related to any Out-of-Pocket Losses, such as notary, fax, postage, copying, mileage, and long-distance telephone charges; and (3) credit monitoring or other mitigative costs that were incurred on or after March 8, 2021.

Extraordinary Losses are losses incurred on or after March 8, 2021, as a result of identity theft as a result of the Data Security Incident. Extraordinary Losses may include falsified tax returns, false claims for government benefits, and false claims for medical treatment.

All Claims are subject to a maximum payment amount, as explained in the Settlement Agreement. The maximum payment for any claim for Out-of-Pocket Expenses is $1,100, for Extraordinary Losses is $5,000, and for Time Spent is $67.50. In addition, in the event the amount of losses claimed and California Cash Payments claimed in the aggregate by Settlement Class Members meets or exceeds $2,650,000, then the payment for your Claim may be reduced pro rata by the Settlement Administrator so that the aggregate value of all payments does not exceed this amount. Please review the Settlement Agreement for further details. All claims for Out-of-Pocket Expenses and Extraordinary Losses will also be subject to a verification process by the Settlement Administrator.

Payment for California Cash Payments and for expenses and/or losses will be paid directly to you electronically unless you request to be paid by check as indicated below.

For each expense and/or loss you believe can be traced to the Data Security Incident, please provide a description of the loss, the date of the loss, the dollar amount of the loss, and the type of documentation you will be submitting to support the loss. You must provide ALL this information for this Claim to be processed. Supporting documents must be submitted with this Claim Form. If you fail to provide sufficient supporting documents, the Settlement Administrator may deny your Claim. Please provide only copies of your supporting documents. The Settlement Administrator will have no obligation to return any supporting documentation to you. A copy of the Settlement Administrator’s privacy policy is available at www.ClearBalanceClassActionSettlement.com.

Costs and/or expenses will be deemed fairly traceable to the Data Security Incident if the Settlement Administrator determines the information submitted could lead a reasonable person to conclude the alleged loss plausibly arose from the Data Security Incident.

Description of the Loss Date of Loss Amount Type of Supporting Documentation
Example:
Payment for Identity Theft Protection Service		 07/17/2021 50.00 Copy of identity theft protection service bill
Example:
Fees paid to a professional to remedy a falsified tax return		 07/20/2021 25.00 Copy of professional services bill
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Additional Information


V. Claim for Reimbursement of Time Spent

Settlement Class Members may submit a claim for up to 3 hours of time spent remedying identity theft, fraud, misuse of personal information, credit monitoring or freezing credit reports, and/or other issues fairly traceable to the Data Security Incident at $22.50 per hour by providing an attestation and a brief description of (1) the action taken in response to the Data Security Incident; and (2) the time associated with each action.

Date of Time Spent Amount of Time Description of the Action Taken
07/17/2021 1 Hour Example: Review my credit report
07/20/2021 1.5 Hours Example: Call with bank to dispute transaction.
Hour(s)
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Additional Information


VI. Upload Supporting Documentation

Accepted file types are: DOCX, DOC, XLS, XLSX, 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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    VII. Select a Method of Payment

    Please select your desired method of payment from the Settlement Administration Account for eligible claims.

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

    Claim Verification: All Claims are subject to verification by the Settlement Administrator. You will be notified if additional information is needed to verify your Claim.

    Assistance: If you have questions about this Claim Form, please call 1-844-999-2066.

    PLEASE KEEP A COPY OF YOUR CLAIM FORM AND PROOF OF SUBMISSION

    Failure to submit required documentation, or to complete all parts of the Claim Form, may result in denial of the claim, delay its processing, or otherwise adversely affect the claim.

    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
    Mailing Address
    City
    State
    Zip Code
    Telephone Number
    Email Address
    Signature
    Date

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

    Click here to edit your Claim.

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