ASC SETTLEMENT CLAIMS FORM
Whitehead v. Advance Stores Company, Inc., No. 5:16-cv-250-RBD-PRL (M.D. Fla.)
I.
INSTRUCTIONS: To make a Tax Refund Fraud Claim complete Section II. To make an Unauthorized Transfer
and Identity Theft Claim complete Section III. You must attach valid documentation to support your claim.
Completed Claims Forms with supporting documentation must be mailed and post marked no later than June 30,
2017 to the following address: ASC Class Action Settlement, C/O Dahl Administration, P.O. Box 3614,
Minneapolis, MN 55403-0614.
II.
TAX REFUND FRAUD CLAIM:
a.
Claimant Information
Last Name:
First Name:
Address:
Address 2:
City:
State:
Zip Code:
b.
IRS Form 14039 – Identity Theft Affidavit
□ I have attached a true and correct copy of the IRS Form 14039 that I submitted to the Internal Revenue
Service (or that was submitted to the Internal Revenue Service on my behalf) in connection with identity
theft that I experienced after March 7, 2016.
c.
Tax Returns
□ I have attached a true and correct copy of my federal and/or state income tax returns for tax year 2015
and/or tax year 2016, which were the subject of tax return fraud.
d.
IRS IP PIN Correspondence
□ I have attached true and correct copies of all correspondence I received from the Internal Revenue
Service regarding my assignment of an IRS Identity Protection PIN.
e.
Certified Tax Preparer or Attorney Invoices
□ I have attached true and correct copies of the bills or invoices from the certified tax preparer or
attorney for which I seek reimbursement and proof that I paid those bills or invoices.
I am seeking reimbursement for the following amount: $
f.
AllClear Identity Theft Insurance
□ I am enrolled in AllClear Credit Monitoring and I sought reimbursement for my expenses related to tax
refund fraud under the identity theft insurance coverage provided through AllClear ID. The amount of
expenses I incurred for a certified tax preparer or attorney that were not reimbursed by the identity theft
insurance coverage is:
$
I certify under penalty of perjury that the foregoing is true and correct.
Executed by:
Date:
_____ / _____ / __________
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III.
UNAUTHORIZED TRANSFER AND IDENTITY THEFT CLAIM
a.
Claimant Information
Last Name:
First Name:
Address:
Address 2:
City:
State:
Zip Code:
b.
Payment Card or Financial Institution(s)
Payment Card
Company and/or
Bank Name(s):
c.
Identity Theft Event and Payment Card or Financial Institution Action
Describe the circumstances surrounding the identity theft you suffered after March 7, 2016 and the reasons
your payment card and/or financial institution refused to waive charges you incurred as a result:
___________________________________________________________________________________
__________________________________________________________________________________
___________________________________________________________________________________
__________________________________________________________________________________
d.
Charges Incurred
List the charges or fees you paid as a result of your identity being stolen after March 7, 2016, and which
your payment card company or financial institution refused to waive:
___________________________________________________________________________________
__________________________________________________________________________________
e.
Proof of Monetary Loss
□ I have attached true and correct copies of any written report to my credit card company and/or financial
institution regarding the identity theft I suffered, and true and correct copies of all receipts, credit card
statements, bank statements, and any other third-party documentation proving that I suffered a monetary
loss as a result of the identity theft.
f.
AllClear Identity Theft Insurance
□ I am enrolled in AllClear Credit Monitoring and I sought reimbursement for these charges and fees under
the identity theft insurance coverage provided through AllClear ID. The amount of charges and fees I incurred
that were not reimbursed by the identity theft insurance coverage is: $_______________________
I certify under penalty of perjury that the foregoing is true and correct.
Executed by:
Date:
_____ / _____ / __________
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