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ln re Mercedes-Benz Emissions Litigation Class Action Settlement Claim Form Claim Form lnstructions Required Documents - Current Owners and Lessees Current Owners and Lessees must include a copy of the following supporting documents with your Claim Formto complete your claim. Please check all the boxes below that apply to you in order to confirm that you have included all the required documents. Please do not send the origlnals because the documents will not bereturned to you. {Former Owners and Lessees do not need to provide these documents.) 'You may need to provide addilionatdocumentation in certain circumstances. You wittbe notified if additional information is needed to complete your claim. lf you.b.gT owning or.leasing and registered the Subject Vehicle after September 14, 2020, and you did not have the AEM installed in your vehicle while you owned or leased it, you are not eligible for payment. lf you no longer own or lease the Subject Vehicle, but you had the AEM installed in the Subject Vehicle while(a)you owned or leased it, ?nd (b) the Subject Vehicle was registered in your name, please fillout Section G andSection E. lf you have questions about filling out this form, please visit mbbluetecsettlement.com or cail 1-BT7-313-0170 To view JND's privacy policy, please visit https://www.indla.com/privacv-policv -5- n A copy of your driver's license or other government-issued photo identification f The repair order or invoice you received at the time the AEM was installed in your Subject Vehicle f Proof that the Subject Vehicle was registered in your name at the time the AEM was installed X Documentation of transportation costs (if seeking Transportation Reimbursement) n Fully executed lndividual Release (a copy of the lndividual Release is attached to the end of this Claim Form) n Proof that you owned or leased and registered the Subject Vehicle. Permitted documentation to prove ownership or lease includes your bill of sale, lease agreement, title, registration from time of purchase orlease, Department of Motor Vehicles ("DMV') registration history, financing agreement, insurance documentation listing your date of purchase or lease, or proof of lease payment; insuiance documentation may suffice for proof of registration. Your documentation must show the'date you acquired or leased the Subject Vehicle, as well as the date you registered it. SECTION D: FORMER OWNERS AND LESSEES ONLY lf you began owning or leasing and registered the Subject Vehicle on or before September 14,2020, and did not have the AEM installed while you owned or leased the Subject Vehicle, check here: Please enter the date you sold the Subject Vehicle or the date you oave. back the Subject Vehicle because your lease. ended (MM/DDf/Yyy): lf your Subject Vehicle was totaled, enter the date the Subject Vehicle was given to an insurance company (or given or sold to a junkyard, salvage dealer, or the equivalent).