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ln re Mercedes-Benz Emissions Litigation Class Action Settlement Claim Form Claim Form lnstructions Required Documentation - Former Owners and Lessees Former Owners and Lessees must include a copy of the following supporting documentation with your Claim Form to complete your claim. Please check the corresponding box to confirm that you have included the specified documentation with your claim. Please do not send the originals as the documents will not be returned to you. *You may need to provide additionaldocumentation in certain circumstances, You will be notified if additionalinformation is needed to complete your elaim. I understand that in order to obtain relief under the Class Action Seftlements, I must sign and date the following certification and provide the documentation listed above. I represent and warrant that I have authority to submit a claim for the Subject Vehicle listed above, and that any of my co-owners and co-lessees of the Subject Vehicle listed above have signed this Claim Form. I affirm under penalty of perjury that all informalion in this Claim Form is true and accurate to the best of my knowledge. Signature Date Print Name; lf you have questions about filling out this form, please visit mbbluetgcsettlement.com or call 1 -87 7-31 3-0 1 70 To view JND's privacy policy, please visit https://www.indla.conl/orivacv-ooligy -6- f| A copy of your driver's license or other government-issued photo identification n Fully executed lndividual Release (a copy of the lndividual Release is attached to the end of this Claim Form) I Proof that you owned or leased and registered the Subject Vehicle on or before September 14, 2A20. Permitted documentation to prove ownership or lease includes your bill of sale, lease agreement, title, registration from time of purchase or lease, Department of Motor Vehicles ("DMV") registration history, financing agreement, insurance documentation listing your date of purchase or lease, or proof of lease payment; insurance documentation may suffice for proof of registration. Your documentation must show the date you purchased or leased the Subject Vehicle, as well as the date you registered it. I Proof that you sold or transferred the Subject Vehicle (permitted documents include your bill of sale, trade- in receipt, copy of title transfer, or proof of lease termination) SECTION E: CERTIFICATION STATEMENT FOR ENTIRE CLAIM FORM - ALL CLAIMANTS MUST COMPLETE CURRENT OWNERS OR LESSEES: Claim Forms must be submitted online at mbbluetecseftlement.com or postmarked no laterthan October 1,2022. FORMER OWNERS OR LESSEES: Claim Forms must be submitted online at mbbluetecsettlemen-t.gom or postmarked by July 12,2021, or by the date the Gourt finally approves the Mercedes Class Action Settlement (if after July 12,20211. Please visit mbbluetecsettlement.com for updates about the deadline to submit your claim.