In Re Ashley Madison Customer Data Security Breach Litigation

MDL No. 2669

Case No. 4:15-MD-02669-JAR (E.D. Mo.)

Claim Form


We Respect Your Privacy

Information you submit on the Claim Form will be kept confidential. To ensure your privacy, the terms of the proposed settlement provide, among other things:

  • “[A]ll Claim Forms submitted by Settlement Class Members, and the Personal Information contained therein, shall be treated as strictly confidential and will not be disclosed to any person other than the Parties’ counsel, the Settlement Administrator, the Court, and any other persons to whom disclosure is necessary to effectuate the terms of this Settlement Agreement, or required by applicable state or federal law.”
  • “The URL of the Settlement Website … shall be a nondescript URL that will not include any reference to Ashley Madison, Avid Life Media, Avid Dating Life, Ruby, Noel Biderman, or any other information identifying the URL as being related in any way to the substance of this litigation or purpose of ashleymadison.com.”
  • Settlement Class Members may select the form of any payment they may be entitled to receive under the proposed Settlement. Settlement Class Members who elect to submit their claims online may elect to receive payment via PayPal, electronic check or mailed check. Settlement Class Members who elect to submit a paper Claim Form, rather than an online claim, will receive a check mailed to them at the address contained on the Claim Form.
  • “No form of payment or any form of delivery of said payment shall be issued with any reference to Ashley Madison, Avid Life Media, Avid Dating Life, Ruby, or any other information identifying the source of the funds as being related in any way to the substance of this litigation, and if the payment form is sent through mail, the Settlement Class Member shall provide the address to where the payment shall be sent.”

The information you provide on the Claim Form will not be used for other purposes, including but not limited to marketing purposes. The information you provide will not be sold, nor will it be provided to others, except insofar as is necessary to effectuate the terms of the Settlement Agreement, or as required by applicable state or federal law. We will use the information that you provide to communicate with you about your claim, which we will do primarily by email.



* Required











CLAIM VALIDATION QUESTIONS

QUESTION ONE (Membership)

Yes (Proceed to next question)
No (You are not eligible to submit a claim)

Please provide all of the information requested below:

IMPORTANT NOTE: To receive a payment, you must submit information sufficient to establish that you created an account on AshleyMadison.com. The only way to be certain that you have submitted information sufficient to determine whether or not you are entitled to a payment is to submit the information requested below.

A. Provide the account number(s) you were given by AshleyMadison.com and/or provide the email address(es) you used to sign up for a user profile.



B. Provide the user name you used on AshleyMadison.com.


C. Please also provide any credit card statements, bank statements, invoices, telephone records, e-mail receipts, other payment records at the end of this form.


QUESTION TWO (Deleted Profiles)


Yes
No

QUESTION THREE (Credit Purchases)


Yes
No

If you answered “Yes” to Question Two and/or Question Three, please complete the following information:

Provide the last four digits of the credit or debit card number(s) used on AshleyMadison.com and full name of the cardholder as the name appeared on the credit or debit card(s) at the time(s) of such purchase(s):
(This information will be used to verify your purchases).

Card 1:






Card 2:






Card 3:







QUESTION FOUR (Other)

(In order to have a recognized loss under this section you must provide proof of losses with your claim).

Yes
No

QUESTION FIVE (Released Information)


Yes
No

DOCUMENTATION UPLOAD

If you upload two documents with the same name, one will overwrite the other. Multiple documents should be named differently.




Mailed Check (A check will be mailed to the address provided on this claim form)
PayPal (A Credit will be made to the PayPal Account associated with the email provided below)
Electronic Check (An Electronic Check will be sent by email to the email address provided on this claim form)


ATTESTATION AND SIGNATURE







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