CompanyThis field is for validation purposes and should be left unchanged.This field is hidden when viewing the formhidden claimant id*This field is hidden when viewing the formhidden LastName* Cody et al., v. City of St. Louis Case No. 4:17-cv-2707-AGF CLAIM FORM You are eligible to complete and submit this Claim Form to be eligible for a Settlement Payment if you were detained in the City of St. Louis, Missouri Medium Security Institution for three or more consecutive days between November 13, 2012 and June 30, 2022. Please complete this form in its entirety. Claim Forms must be postmarked for mail or filed online no later than June 29, 2026 . CLASS MEMBER INFORMATION Claimant ID*This is the 8-digit number printed about your name and address on the Notice that was mailed to you.Name:* First Middle Last Current Street Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Code PhoneEmail *If your last name has changed since you were in custody at MSI, please include legal documentation, such as a marriage or divorce certificate, with your claim to support the name change. If you are filing a claim on behalf of a deceased Class Member, please include a copy of his/her death certificate and legal documentation to show that you have authority to act on his/her behalf with the claim. CLAIMANT VERIFICATION Check the boxes below if you agree with the following statement:Signature* I was detained in the St. Louis Medium Security Institution for three or more consecutive days between November 13, 2012 and June 30, 2022. Signature* Throughout my detention at the St. Louis Medium Security Institution, I experienced inhumane treatment including exposure to one or more of the following conditions: extreme temperatures, poor ventilation, overflowing sewage, insect and rodent infestations, mold, or overcrowding. CLAIMANT DECLARATION Signature* I hereby give assurances that the information on this Claim Form is correct. Print Name*Date* MM slash DD slash YYYY Claim Forms can be submitted online or by mail to: St. Louis MSI Lawsuit c/o Atticus Administration PO Box 64053 St. Paul, MN 55164 Email: [email protected] CAPTCHAUnique IDClaimFormNo
