ClaimFormNoObjection Form SUBMIT BY JUNE 10, 2024 T.D. v. Mercy Health Settlementc/o Atticus AdministrationCircuit Court of St. Louis County, Missouri, Case No. 20SL-CC05974 Your objection must: (i) include your full name, address, and telephone number; (ii) state the case name and number of this case; (iii) include a statement of your specific objections; (iv) state all grounds for the objection, with factual and legal support for the stated objection, including any supporting materials; (v) identify any other objections you have filed, or have had filed on your behalf, in any other class action lawsuits in the last four years; and (vi) be signed by you. If you are represented by an attorney, you must also provide the name and telephone number of your attorney.(i) include your full name, address, and telephone numberName* First Middle Initial Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Phone*Claimant ID* (ii) state the case name and number of this caseT.D. v. Mercy Health Settlementc/o Atticus AdministrationCircuit Court of St. Louis County, Missouri, Case No. 20SL-CC05974(iii) include a statement of your specific objectionsStatement of Objections*(iv) state all grounds for the objection, with factual and legal support for the stated objection, including any supporting materialsSection V any other objections*Upload your Supporting Material Here* Drop files here or Select files Accepted file types: pdf, jpg, jpeg, bmp, png, docx, doc, xlsx, xls, Max. file size: 16 MB, Max. files: 5. (v) identify any other objections you have filed, or have had filed on your behalf, in any other class action lawsuits in the last four yearsStatement of grounds*(vi) be signed by you.Acknowledgement* I am requesting to Object from this settlement Printed Signature* Are you represented by an attorney?* Yes No Attorney Name and Phone Number CAPTCHAUnique IDNameThis field is for validation purposes and should be left unchanged.