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Must Be Postmarked No Later Than October 30 2012 VZGL1 The United States District Court District of Northern California Ruwe v. Cellco Partnership d/b/a Verizon Wireless Civil Action No. 07-cv-0369 JSW Class Action Claim Form In order for you to qualify to receive payments related to Ruwe v. Cellco Partnership d/b/a Verizon Wireless as described in the Notice of this Settlement the Class Notice you must complete and submit this Claim Form. To file a claim online please visit www. verizonwirelesssettlement. com* Your Claim Form must be submitted online or postmarked if submitting by mail by October 30 2012. If submitted by mail please send via first class mail to Verizon Wireless Settlement c/o Gilardi Co. LLC P. O. Box 808054 Petaluma CA 94975-8054 This Claim Form may be submitted only by persons who are or were Verizon Wireless customers in California with a contract with Verizon Wireless for personal wireless telephone service who were charged or paid a flat 5 late fee on an overdue bill from June 12 2003 to April 26 2012 and/or a 15 reconnect fee from December 1 2004 to April 26 2012. If other individuals in your household have separate accounts with Verizon Wireless and have paid either the 5 late fee or the 15 reconnect fee each individual account holder must submit a separate claim form* You must complete all information below and complete an electronic certification or sign your form if submitting by mail in order to receive any benefits from this settlement. Please do not use red ink or pencil* Claimant Information First Name M. I. Last Name Address 1 City State Zip Code Either state your Verizon account number OR State the telephone number you had with Verizon If you received a notice regarding the settlement this is because Verizon Wireless s records indicate that you paid at least one of the following a flat 5 late fee on an overdue bill from June 12 2003 to April 26 2012 and/or a 15 reconnect fee from December 1 2004 to April 26 2012. In order to claim an award you must check at least one box. I paid a flat 5 late fee between June 12 2003 and April 26 2012 on the Verizon Wireless account listed above. I paid a 15 reconnect fee between December 1 2004 and April 26 2012 on the Verizon Wireless account listed above. I certify that I have accurately completed the information in this form and that the information set forth is true correct and complete to the best of my knowledge. verizonwirelesssettlement. com* Your Claim Form must be submitted online or postmarked if submitting by mail by October 30 2012. If submitted by mail please send via first class mail to Verizon Wireless Settlement c/o Gilardi Co. If submitted by mail please send via first class mail to Verizon Wireless Settlement c/o Gilardi Co. LLC P. O. Box 808054 Petaluma CA 94975-8054 This Claim Form may be submitted only by persons who are or were Verizon Wireless customers in California with a contract with Verizon Wireless for personal wireless telephone service who were charged or paid a flat 5 late fee on an overdue bill from June 12 2003 to April 26 2012 and/or a 15 reconnect fee from December 1 2004 to April 26 2012.