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ln re Mercedes-Benz Emissions Litigation Class Action Setflement Claim Form Claim Form lnstructions o lf you are an Eligible Current Owner/Lessee, a repair order showing the Approved Emission Modification("AEM') is installed in your Subject Vehicle ' lf you are an Eligible Gurrent Owner/Lessee, you must schedule an appointment and have theAEM installed beforg submitting your Glaim Form and required documents. you will be eligiblefor a Class tlgl!"f Payment onlv after the AEM is installed (at no charge to you), you can checkwhether the AEM is available now for your Subject Vehicle by visiting tfre 'setilement Website,mbbluetecsettlement.com, where you can type in your Vehicle ldentificati-on Number 1"Vitt"; to checkthe AEM availability for your vehicle, or review a listing of all Subject Vehicle models that are ready forthe AEM installation. lf your vehicle is not listed, you will be notified when the AEM becomes available.Please continue to check the Settlement Website for updated information. you may also call 1-g77-313-0170 toll-free to find out whether an AEM is availabie for your Subject Vehicle. You can find a list of the types of documents that fulfill the documentation requirements below. CLAIM REVIEW AND PAYMENT PROCESS: ' After you have submitted your Claim Form, the Settlement Administrator will review your Claim Form andsupporting documents for completeness and eligibility. The Settlement Administrator will also screen theclaims for fraud and determine the payment amount. - o lf the Claim Form or required documentation is incomplete, illegible, or otherwise deficient, the SetgementAdministrator will notify you that there is a deficiency oithat more information is needed. lf you do not timelycomply and/or are unable to produce the requested information, your claim will be denied and you will notreceive a Class Member payment. r The payment amount you may receive depends on when you purchased or leased the subject Vehicle,whether you owned or leased the Subject Vehicle at the time the AEM was installed in the SubjeciVehicle, the number of claims made per Subject Vehicle and, for Eligible Current Owners/Lessees,whether your Subject Vehicle qualifies for possible additional paymentsi The Setgement Administratorwill issue the payment after your claim is deemed complete and you are determined to be eligible for aClass Member Payment. lf you have questions about filling out this form, please visit mbbluetecsetilement.com or call'l-gT7-313-O1TO To view JND's privacy policy, please visit httos://www.indla.com/privacv-policv -2-