In re: Checkers Data Security Breach Litigation

Case No. 8:19-cv-01386-VMC-CPT

UNITED STATES DISTRICT COURT FOR THE MIDDLE DISTRICT OF FLORIDA

THIS CLAIM FORM MUST BE SUBMITTED BY: OCTOBER 28, 2020

CLASS MEMBER INFORMATION:

The Settlement Administrator will use this information for all communications regarding this Claim Form and the Settlement. If this information changes prior to distribution of the settlement benefits, you must notify the Settlement Administrator in writing at the address above.

First Name *

Last Name *

Street Address *

Street Address 2 *

City *

State *

Zip Code *

Telephone Number *

Email Address

* Required Fields

SETTLEMENT BENEFITS

Documented Expense Reimbursement
If you have documentation establishing that you suffered out-of-pocket losses, unreimbursed charges, or time spent remedying issues relating to the Checkers Data Breach, you can make a claim for reimbursement of up to $5,000, including up to 4 hours of documented time at $20 per hour. You must submit supporting documentation for this claim.

Attested Expense Reimbursement
If you do not have documentation, you will still be eligible to self-certify your losses and time spent remedying issues relating to the Checkers Data Breach. As compensation, you can make a claim to receive four (4) restaurant vouchers of $5.00 each, which may be redeemed at any Checkers or Rally’s restaurant, valid for one (1) year and freely transferrable.

1. Did you use a credit or debit card at an affected Checkers location during the exposure window for that particular location (click here to see a list of locations and exposure windows)?

Yes (Proceed to Question 2)

No (You are not eligible to submit a claim)

2. What is the restaurant number of the Checkers location where you made your purchase (list up to three) and the dates on which you made your purchases (list up to three)?

(click here to see a list of locations and restaurant number)

Restaurant State

Restaurant Address

Restaurant Number

Date(s) visited

Restaurant State

Restaurant Address

Restaurant Number

Date(s) visited

Restaurant State

Restaurant Address

Restaurant Number

Date(s) visited

3. Do you have proof of your purchase using a credit or debit card at an affected Checkers location during the exposure window? (Examples: purchase receipt, credit card statement, bank statement)

Yes (Skip to Question No. 5)

No (Proceed to Question 4)

4. If you made a credit or debit card purchase at an affected Checkers location during the Data Breach exposure window for that location, you can make a claim to receive four (4) restaurant vouchers of $5.00, valid for one (1) year and freely transferrable. You must complete the attestation and sign the Claim Form below.

DOCUMENTED CLAIMS FOR OUT-OF-POCKET LOSSES, UNREIMBURSED CHARGES, OR TIME SPENT REMEDYING ISSUES RELATING TO THE DATA BREACH

5. Do you have documents proving you experienced out-of-pocket losses or unreimbursed charges, or that you spent time remedying issues relating to the Checkers Data Breach? If so, you may submit a claim, with supporting documentation, for up to $5,000 in out-of-pocket losses, unreimbursed charges, or time spent remedying issues related to the Checkers Data Breach.

Yes (Proceed to the chart below)

No (You are not eligible to submit a claim under this category. Please refer to Question 4 for instructions on how to submit a claim to receive four (4) restaurant vouchers of $5.00, valid for one (1) year and freely transferrable.)

If you fail to provide the required documentation to support a claim under this category (or if the documentation you provide is deemed insufficient by the Settlement Administrator), your claim will be processed under Question 4. You will not be entitled to a cash payment. However, if your claim for undocumented losses is approved, you will still receive four (4) restaurant vouchers of $5.00 each, redeemable at any Checkers or Rally’s restaurant, valid for one (1) year, and freely transferrable.

Loss Type (Check all that Apply)	Date of Loss (MM/DD/YYYY)	Amount of Loss	Description of Loss	Description of Supporting Documentation (Identify what you are attaching and why)
Costs and expenses spent addressing identity theft or fraud as a result of the Checkers Data Breach	Costs and expenses spent date	Costs and expenses spent amount	Costs and expenses spent description	Examples: Receipt or account statement reflecting fuel costs for driving to bank or filing police report that relate to some other documentation provided; Receipt for hiring service to assist you in addressing identity theft
Losses caused by restricted access to funds (i.e., costs of taking out a loan, ATM withdrawal fees) as a result of the Checkers Data Breach	Losses caused by restricted access date	Losses caused by restricted access amount	Losses caused by restricted access description	Examples: Account statement with ATM withdrawal fee highlighted; Loan agreement or bank statement with additional interest paid highlighted
Preventative costs including purchasing credit monitoring, placing security freezes on credit reports, or requesting copies of credit reports for review as a result of the Checkers Data Breach	Preventative costs date	Preventative costs amount	Preventative costs description	Example: Receipts or account statements reflecting purchases made for credit monitoring services or to place a credit freeze
Late fees, declined payment fees, overdraft fees, returned check fees, customer service fees, and/or card cancellation or replacement fees as a result of the Checkers Data Breach	Late fees date	Late fees amount	Late fees description	Example: Account statements reflecting overdraft fees
Documented time spent remedying issues relating to the Checkers Data Breach	Documented time spent date	Number of Hours Spent (max = 4 hours)	Describe what you did	Example: Phone bill reflecting time spent on phone with bank. You may make a claim for up to 4 hours of documented time at $20 per hour total.
Unauthorized charges on credit or debit card reasonably caused by the Checkers Data Breach that were not reimbursed or other fraud losses reasonably caused by the Checkers Data Breach	Unauthorized charges date	Unauthorized charges amount	Unauthorized charges description	The following is required to recover for this category of loses: (1) a copy of the statements that show the fraudulent charges, and (2) correspondence from financial institution declining to reimburse you the charges. If you do not have written correspondence, provide in writing the approximate date that you reported and to whom you reported the fraudulent charge.
Other (provide detailed description)	Other date	Other amount	Other description	Please provide detailed description and supporting documentation

DOCUMENTATION

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected. Please confirm in the grid below that your file has been successfully uploaded.

Select File for Upload:

File Description:

File List: No Files Selected

ATTESTATION AND SIGNATURE

I do hereby swear (or affirm), under penalty of perjury, that the information provided above is true and accurate to the best of my knowledge and that the compensation I am claiming is based on losses I reasonably believe to the best of my knowledge were the result of the Checkers Data Breach.

Signature *

Date

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
Street Address
Street Address 2
City
State
Zip Code
Email Address
Telephone Number

THIS CLAIM FORM MUST BE SUBMITTED BY: OCTOBER 28, 2020

Your Claim Form has been submitted successfully.