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Approved Consent Decree
Conanan, et al. v. Tanoue, Civil Action No. 00-CV-3091 (ESH)
CLAIM FORM
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IMPORTANT: PLEASE READ THE CONSENT DECREE AND ALL ATTACHED EXHIBITS BEFORE COMPLETING THIS FORM. IF YOU ARE AFRICAN-AMERICAN AND WORKED FOR THE FEDERAL DEPOSIT INSURANCE CORPORATION ("FDIC") AT ANY TIME FROM MAY 13, 1992 TO MARCH 31, 2001, YOU MAY BE ELIGIBLE TO RECEIVE MONEY UNDER THIS SETTLEMENT (CONSENT DECREE), AS A MEMBER OF THIS CLASS ACTION. IF YOU WOULD LIKE TO BE CONSIDERED FOR MONETARY PAYMENT UNDER THIS CONSENT DECREE, YOU MUST COMPLETE AND SIGN THIS CLAIM FORM UNDER OATH SUBJECT TO THE PENALTY OF PERJURY, MAIL IT IN AN ENVELOPE, POSTMARKED BY THE UNITED STATES POSTAL SERVICE, ON OR BEFORE JULY 16, 2001 TO:
SETTLEMENT SERVICES, INC.
P.O. BOX 11190
ALLAHASSEE, FL 32302-3190
IF YOU ARE A CLASS MEMBER AND SUBMIT THIS CLAIM FORM, YOU MAY NOT OPT OUT OF THIS CLASS ACTION AND WILL BE BOUND BY THE TERMS OF THE CONSENT DECREE.1
IF YOU SUBMIT BOTH A CLAIM FORM AND A REQUEST TO OPT OUT, THE CLAIMS ADMINISTRATOR WILL CONCLUDE THAT YOU DO NOT WANT TO OPT OUT OF THIS CLASS ACTION.
IF YOU DO NOT RETURN THIS CLAIM FORM BY THE DATE ABOVE, YOU WILL NOT BE ELIGIBLE TO RECEIVE MONEY IN THIS CASE.
NO LATE CLAIM FORMS WILL BE CONSIDERED.
I. GENERAL INFORMATION
| 1. |
Name: |
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(first) |
(middle) |
(last) |
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Prior Name: |
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(first) |
(middle) |
(last) |
| 2. |
Mailing Address: |
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(street or P.O. Box ) |
(Apt. No.) |
|
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| (city) |
(state) |
(zip code) |
| 3. |
Telephone Nos.: |
/
-
(day/work)
/
-
(evening/home)
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Best time to reach you |
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Other Telephone Nos.: |
/
-
|
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E-mail Address: |
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| 4. |
Date of Birth: |
/
/
(month/day/year) |
| 5. |
Social Security No.: |
- -
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II. CLAIM INFORMATION
| 1. |
Are you African-American? (i.e., Black) |
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Yes 
No
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| 2. |
Did you apply between May 13, 1992 and March 31, 2001 for a permanent or temporary promotion under a vacancy announcement of the FDIC (this excludes details, expressions of interest, and term appointments)? |
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Yes
No
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| 3a. |
Have you brought a claim against the FDIC alleging (1) denial of, or delay in, a promotion because of your race or color that occurred anytime from May 13, 1992 to March 31, 2001; or (2) denial of, or delay in, a promotion that occurred anytime from May 13, 1992 to March 31, 2001 in reprisal for filing an EEO claim? |
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Yes
No
(If you brought more than one claim, please copy this form and answer question 3b. for each one.)
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I DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING IS TRUE AND CORRECT. I UNDERSTAND THAT I COULD BE SUBJECT TO CRIMINAL PENALTIES FOR FILING A FALSE CLAIM FORM OR PROVIDING ANY FALSE INFORMATION ON THIS CLAIM FORM.
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Date
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Signature
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Please keep a copy of your completed Claim Form for your records.
If you would like confirmation that your Claim Form has been received,
you may send it by certified mail, return receipt requested
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Last Updated 10/16/2003 |
conanancd@fdic.gov |
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