Class Action Settlement Claim Form

Doe et al vs The City and County of San Francisco el al

Case Number CGC-16-551618

Superior Court of California County of San Francisco

The deadline to submit this claim form is August 30, 2022.

Class Members will not receive a pro rata share (equal portion) of the Settlement but will be bound by the terms of the release if they do not timely submit a claim form. This claim is being submitted by (or on behalf of):

Patient First Name

Patient Last Name

Address 1

Address 2

City

State

Zipcode

This Claim Form is being submitted by someone other than the Patient named above.

By signing below, I attest that the foregoing is true and accurate on penalty of perjury under the laws of the state of California.

Signature

Date