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ln re Mercedes-Benz Emissions Litigation Class Action Settlement Glaim Form Claim Form lnstructions Please provide your name and contact information below. You must notify the Settlement Administrator if your contact information changes after you submit your Claim Form; otheruyise you may not receive your Ciass Member Payment. All claimants must complete this Section B. lf you are making a claim as an Eligibte Former Owner or Lessee, you must provide the information for the Subject Vehiile that you formerly owned or leased. Please provide the model and model year of your Subject Vehicle in the box below. Be sure to write clear andneatly. lf you have a claim for more than one Subject Vehicle, you must submit a separate Claim Form for each Subject Vehicle. Model Model Year Please enter the VIN of the Subject Vehicle you entered above. The VIN may be located on your vehicle registration, your car title or in vehicle maintenance records from your dealer. Vour Mercedes,Benz Owner's Manual can also direct you to the physical location of the VIN on your vehicle. To avoid confusion between letters and numbers, please enter numbers in the same form as the chart below. Be sure to write clear and nealy. Zero One Two Three Four Five Six Seven Eight Nine g I 2 3 4 5 6 7 8 9 SECTION A: NAME AND CONTACT INFORMATION _ ALL CLAIMANTS MUST cOMPLETE First Name Middle lnitial Last Name Suffix James Nale Mailing Address PO Box 1494 City State Zip Gode Ellensburg WA 9892&1907 EmailAddress Best Telephone Number to Contact You sEcrloN B: vEHlcLE INFORMATI0N - ALL CLA|MANTS MUST coMpLETE W D Y F E I c D 0 G P 3 0 I 4 1 4 Enter the lTdigit VIN in the boxes above. lf you have questions about filling out this form, please visit EbblueteqsejtleJnent. com or call 1 -97 I -g 1 A-0 1 T O To view JND's privacy policy, please visit https://www.indla.com/pdvacy-policv -3-