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Nevada Restaurant Services Data Incident Settlement

CLAIM FORM

This Claim Form should be filled out and submitted online or by mail if you had documented out-of-pocket expenses,
lost time spent, or documented unreimbursed extraordinary monetary losses as a result of the Data Incident involving
Nevada Restaurant Services, Inc (“NRS”), or if you are requesting credit monitoring or the alternative cash payment.

Checks will be mailed, or electronic payments will be made, to eligible Settlement Class Members if the settlement
is approved by the Court.

The Settlement Notice describes your legal rights and options. Please visit the official Settlement Website,
www.NevadaRestaurantServicesDataSettlement.com or call toll-free number, (833) 522-7586, for more
information.

Your claim must be submitted online or postmarked by September 17, 2024, to be considered for payment.
Only one claim form may be submitted per Settlement Class Member.
Claim submission options:
 File a claim online at www.NevadaRestaurantServicesDataSettlement.com
 Print this form, complete the form in its entirety, and mail to the Claims Administrator at:

Sanguinetti v. NRS
c/o Kroll Settlement Administration LLC
PO Box 225391
New York, NY 10150-5391

YOU MUST INCLUDE YOUR CLASS MEMBER ID.

You can locate your Class Member ID on the postcard Notice that was sent to you.

1. SETTLEMENT CLASS MEMBER INFORMATION

Class Member ID: 8 3 0 4 3 ___ ___ ___ ___ ___ ___ ___ ___

Name (REQUIRED): ________________________________ ___ __________________________________________

First Name Mi Last Name

_________________________________________________________________________________________________
Number and Street Address (REQUIRED)

_____________________________________________ ___ ___ ___ ___ ___ ___ ___ - ___ ___ ___ ___
City (REQUIRED) State (REQUIRED) Zip Code (REQUIRED)

Telephone Number (REQUIRED): ( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___

Email Address (optional): _________________________________________@______________________.____________

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2. PAYMENT ELIGIBILITY INFORMATION

Please review the Notice and sections 2.1 through 2.2 of the Settlement Agreement (available at
www.NevadaRestaurantServicesDataSettlement.com) for more information on who is eligible for a payment and
the nature of the expenses or losses that can be claimed.

If you wish to receive your cash payment electronically, please provide the email address associated with
your PayPal, Venmo, or Zelle account below, sign, and return this Claim Form. If you do not select an
electronic payment option, a check will be mailed to the address above.
The email address associated with my PayPal account is [OPTIONAL]:

The email address associated with my Venmo account is [OPTIONAL]:

The email address associated with my Zelle account is [OPTIONAL]:

3. CLAIM TYPE AND REIMBURSEMENT SELECTION

Please provide as much information as you can to help determine if you are entitled to a Settlement payment.
TO FILL OUT THIS SECTION:
1. Check the box for each category of documented out-of-pocket expenses, fraudulent charges, or lost time
that you incurred between January 16, 2021, and September 17, 2024, as a result of the Data Incident.
2. Fill in the total amount you are claiming for each category and provide descriptions when necessary.
3. Attach documentation clearly outlining the charges as you described them.
Documented Expense Reimbursement:
You may receive reimbursement for documented out-of-pocket expenses or costs incurred as a result of the Data
Incident, up to a total of $350, which includes any claim for lost time made below.
Unreimbursed bank fees as a result of the Data Incident.
Total amount claimed for this category $__________

I have attached a copy of a bank or credit card statement or other proof of the fees or charges.
(You may mark out any transactions that were not fraudulent or not relevant to your claim)

Date reported:____________________________________________________________

Description of the person(s) and/or companies to whom you reported the fraud:

________________________________________________________________________________________

________________________________________________________________________________________

Other incidental telephone, internet, postage, or gasoline (for local travel only) expenses directly related
to the Data Incident.
Examples - Long distance phone charges, cell phone charges (only if charged by the minute), data charges
(only if charged based on the amount of data used)

Total amount claimed for this category $________

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I have attached a copy of the bill from my telephone or mobile phone company or internet service provider,
postage provider, or gasoline provider that shows the charges, receipts, or other proof or purchase of the
fees or charges.
(You may mark out any transactions that were not fraudulent or not relevant to your claim)
Fees for credit reports, credit monitoring, or other identity theft insurance product purchased
between January 16, 2021, and September 17, 2024, related to the Data Incident.
Total amount claimed for this category $________
I have attached a copy of a receipt or other proof of purchase for each credit report or product purchased
related to the Data Incident.
(You may mark out any transactions that were not fraudulent or not relevant to your claim)
Hours of time spent dealing with the Data Incident (which will be calculated and paid at a rate of $35 per
hour, max of 4 hours).
Total number of hours claimed __________
In order to receive this payment, you must describe what you did and how the claimed lost time was
spent related to the Data Incident, along with an attestation under penalty of perjury that you spent
the claimed time responding to issues raised by the Data Incident.
I attest under penalty of perjury and the laws of the United States and my state of residence that I spent the
below described lost time responding to issues raised by the Data Incident:

____________________________________________________________________________________________

____________________________________________________________________________________________
Documented Extraordinary Loss Reimbursement
If you wish to receive reimbursement of actual, documented, and unreimbursed losses (up to $10,000), with
submission of a proof of loss under penalty of perjury, that were caused by the Data Incident, occurred between
January 16, 2021 and September 17, 2024, and not already covered by one or more of the other categories of
Settlement benefits, describe the unreimbursed losses claimed (including the amount of each loss), sign the
attestation at the end of this Claim Form, and attach supporting documentation (if you provide account statements as
part of proof required for any part of your claim, you may mark out any unrelated transactions if you wish). By
signing the attestation below, you are affirming that the claimed losses were caused by the Data Incident.
Describe all actual, documented, and unreimbursed losses (including the amount of each loss and the total amount
claimed) that were caused by the Data Incident.
Date Description of Loss Amount

___ ___/___ ___/___ ___ ___ ___ $ ___ ___ ___ ___.___ ___
mm/dd/yyyy

___ ___/___ ___/___ ___ ___ ___ $ ___ ___ ___ ___.___ ___
mm/dd/yyyy

___ ___/___ ___/___ ___ ___ ___ $ ___ ___ ___ ___.___ ___
mm/dd/yyyy

Total: ___ ___ ___ ___. ___ ___

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I have attached documentation showing that the claimed loses were caused by the Data Incident.

Check this box to confirm that you have exhausted all applicable insurance policies, including credit
monitoring insurance and identity theft insurance, and that you have no insurance coverage for these
fraudulent charges.

Credit Monitoring
All Settlement Class Members are eligible to claim three (3) years of credit monitoring and identity restoration
services.
If you select “YES” for this option, you will need to follow instructions and use an activation code that you receive
after the Settlement is final. Credit Monitoring Protections will not begin until you use your activation code to enroll.
Activation instructions will be provided to your email address. If you do not have an email address, your activation
code and instructions will be sent to your home address listed on this Claim Form.
YES, I want to sign up to receive three (3) years of free Credit Monitoring

Email Address: _______________________________________ @__________________.__________

Alternative Cash Payment

You may choose to receive a cash payment, estimated to be $50, in lieu of all the other benefits offered. The amount
of the cash payments may be reduced depending upon the number of claims filed.
Do you wish to receive an alternative cash payment instead of all other benefits?

YES

NO

4. SIGN AND DATE YOUR CLAIM FORM

I declare under penalty of perjury and the laws of the United States and my state of residence that the information
supplied in this Claim Form by the undersigned is true and correct to the best of my recollection, and that this
form was executed on the date set forth below.

______________________________ ______________________________ ___ ___ / ___ ___ / ___ ___

Signature Print Name Date (mm/dd/yyyy)

5. SUBMIT YOUR CLAIM FORM

This Claim Form and all supporting documentation must be either submitted online at
www.NevadaRestaurantServicesDataSettlement.com or postmarked by September 17, 2024, and mailed to:

Sanguinetti v. NRS
c/o Kroll Settlement Administration LLC
PO Box 225391
New York, NY 10150-5391

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