Exclusion From Class Action

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ELECTRONIC REQUEST FOR EXCLUSION FROM CLASS SETTLEMENT

Marcella Brock & Adenike Fajemisin v. Dignity Health, et al..
Superior Court of California, Los Angeles County
Case No. BC616408

TO EXCLUDE YOURSELF FROM THE SETTLEMENT IN THIS CASE, YOU MUST COMPLETE, SIGN AND RETURN THIS FORM BY U.S. MAIL, FAX, OR E-MAIL, OR SUBMIT ONLINE BY MAY 29, 2018

 

By signing and returning this Request For Exclusion From Class Action Settlement Form, I am certifying that I have carefully read the Notice Of Proposed Class Action Settlement and that I wish to be excluded from the Settlement described therein. I understand that this means I will not be eligible to receive any Settlement Payment and I will not have standing to object to the Settlement or Class Counsel’s Motion for Attorney’s Fees and Costs or Plaintiff’s Service Award. I also understand that, if I am excluded from the Settlement, I may bring a separate lawsuit seeking damages, but that there is no guarantee of the outcome of such case and I might recover nothing or less than what I would have recovered if I had filed a Settlement Claim And Consent To Join Form under this Settlement.

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    I have received the Notice Of Proposed Class Action Settlement, the Settlement Claim And Consent To Joint Form, and this Request For Exclusion From Class Action Settlement Form. I submit this Request For Exclusion From Class Action Settlement Form to request exclusion from the Settlement in this case.

    I declare under penalty of perjury under the laws of the United States of America that the information in this Request For Exclusion From Class Action Settlement Form is true and correct to the best of my knowledge and belief.

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    Last 4 Digits of SSN (required)

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    FILING BY MAIL.     You may submit a Request for Exclusion by signing, completing, and mailing this Form to the address below. This is not a Claim Form. Do not mail this Exclusion Form if you wish to remain in the settlement class. CLICK HERE TO DOWNLOAD PDF FORM
            Trustaff Healthcare Solutions, LLC Claims Administrator
            c/o Phoenix Settlement Administrators
            P.O. Box 7208
            Orange, CA 92863
            Phone: 1-800-523-5773
            Fax: 949-209-2503
            Email: notice@phoenixclassaction.com
            Website: www.phoenixclassaction.com/dignity-health