If you received a personalized notice in the mail or via email with a Notice ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Notice ID exactly as it appears on your personalized Notice, (i.e. 12345678).

The deadline for submitting this proof of claim form is

If you were notified that your personal information could have been accessed in a cyberattack perpetrated on SARC on or about July 5, 2021, in which third-party criminals gained unauthorized access to SARC’s network, encrypted some of SARC’s systems, and gained unauthorized access to the personal information of Plaintiffs and other consumers, you are a “Class Member.”

As a Class Member, you may be eligible to receive up to $500 total for ordinary unreimbursed losses, including up to $60 in compensation for lost time incurred as a result of the Data Incident (“Ordinary Losses”), and up to $2,500 cash payment for reimbursement of extraordinary, proven monetary losses that are reasonably and fairly traceable to the Data Incident (“Extraordinary Losses”). In addition, Class Members who reside in California and who submit a Valid Claim for ordinary or extraordinary losses are also eligible to receive a separate, California statutory damages award in the amount of $100, subject to the capped amounts for ordinary and extraordinary losses.

If you intend to make a claim for Ordinary Losses or Extraordinary Losses, you will need to submit supporting documentation.

You can also request two (2) years of free single bureau credit monitoring and identity theft protection services by completing and submitting this Claim Form. You do not need to make a claim for Ordinary Losses or Extraordinary Losses to request the identity theft protection services.

Please read the claim form carefully and answer all questions. Failure to provide required information could result in a denial of your claim.

Cash payments amounts may be reduced pro rata (proportionately) depending on how many people submit such claims. Complete information about the Settlement and its benefits are available at www.SARCDataSettlement.com.

This Claim Form may be submitted electronically via the Settlement Website at www.SARCDataSettlement.com or completed and mailed to the address below. Please type or legibly print all requested information, in blue or black ink. Mail your completed Claim Form, including any supporting documentation, by U.S. mail to:

SARC Settlement Administrator
1650 Arch Street, Suite 2210
Philadelphia, PA 19103

I. CLASS MEMBER NAME AND CONTACT INFORMATION

* Required Fields

II. IDENTITY THEFT PROTECTION
III. REIMBURSEMENT FOR ORDINARY LOSSES

All members of the Settlement Class who submit a Valid Claim using this Claim Form are eligible for the following documented out-of-pocket expenses, not to exceed $500 per member of the Settlement Class, that were incurred as a result of the Data Incident:

Cost Type
(Fill all that apply)		 Approximate Date of Loss Amount of Loss
Out of Pocket Expenses

Description of Supporting Documentation (Identify what you are attaching and why):

Example: Phone bills, gas receipts, postage receipts; detailed list of locations to which you traveled (i.e. police station, IRS office), indication of why you traveled there (i.e. police report or letter from IRS re: falsified tax return) and number of miles you traveled
Fees for credit reports, credit monitoring, or other identity theft insurance product

Description of Supporting Documentation (Identify what you are attaching and why):

Example: Receipts or account statements reflecting purchases made for Credit Monitoring & Insurance Services
Time Expenditures

Time Expenditures: Hours for time spent dealing with the Data Incident

IV. REIMBURSEMENT FOR EXTRAORDINARY LOSSES

All members of the Settlement Class who have suffered a proven monetary loss and who submit a Valid Claim using this Claim Form are eligible for up to $2,500 if: (i) the loss is an actual, documented and unreimbursed monetary loss; (ii) the loss was more likely than not caused by the Data Incident, and an attestation by Claimant that they have not received any notice that their information was exposed in a prior unrelated data breach; (iii) the loss occurred between July 5, 2021 and the Claims Deadline; (iv) the loss is not already covered by one or more of the normal reimbursement categories; and the settlement class member made reasonable efforts to avoid, or seek reimbursement for, the loss, including but not limited to exhaustion of all available credit monitoring insurance and identity theft insurance; and (v) confirmation that claimant enrolled in the complementary credit monitoring and identity theft services that SARC offered. Please provide an itemized list of any Extraordinary Losses below, if you need additional lines, you may submit additional pages containing this information with your claim:

Cost Type Approximate Date of Loss Amount of Loss

Description of Supporting Documentation (Identify what you are attaching and why):
V. SUPPORTING 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.

File List: No Files Selected

    VI. CALIFORNIA SETTLEMENT SUBCLASS MEMBERS
    VII. PAYMENT SELECTION

    Please select one of the following payment options, which will be used should you be eligible to receive a settlement payment:

    You have successfully requested a payment. Click here if you would like to choose a different payment method.

    VIII. ATTESTATION & SIGNATURE

    I swear and affirm that the information I have supplied in this Claim Form is true and correct to the best of my recollection, and that this form was executed on the date set forth below.

    I understand that all information provided on this Claim Form is subject to verification and that I may be asked to provide supplemental information by the Claims Administrator or Claims Referee before my claim will be considered complete and valid.

    Your Claim Form has been submitted successfully.

    Please print this page for your records.

    Your Claim Details
    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
    Phone Number
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Info@SARCDataSettlement.com

    Click here to edit your Claim.

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