CLAIM FORM

CLAIMANT CONTACT INFORMATION



1. MORTGAGE LOAN INFORMATION



Do not leave blank. If the exact date is unknown, input approximate date.






Do not leave blank. If the exact amount is unknown, input approximate amount of your prepayment charge.
Do not leave blank. If the exact rate is unknown, input approximate rate.


Do not leave blank. If the exact date is unknown, input approximate date.
2. SPECIAL CIRCUMSTANCES (if applicable)







Where any of the above Special Circumstances occurred between the date of signature of your mortgage loan for which eligible Prepayment Charges were paid and within 36 months prior to the date of prepayment of that same mortgage loan. If you want to qualify as having experienced Special Circumstances, you must provide the above-mentioned certificate with this Claim Form.
3. SUPPORTING DOCUMENTATION (including discharge statement) (Optional, except in the case of Special Circumstances)

Drag supporting documentation here

4. CLAIM CERTIFICATION & RELEASE
To obtain compensation under the Settlement, you must attest to the following certification:
  1. I am a member of the Class or the authorized representative of a Class Member or Class Member's estate that is a member of the Class.
  2. I confirm that all of the information in this Claim Form is true and correct.
  3. I understand that by submitting this claim, I am authorizing the Claims Administrator to contact me or my representative as the Claims Administrator deems appropriate for more information and/or to audit my claim.
  4. If Special Circumstances apply: I confirm that I had to prepay my mortgage due to one of the Special Circumstances mentioned above







If you have any questions while completing the Claim Form please contact the Claims Administrator at:
Velvet Payments
5900 Andover Ave.
Suite 1
Montreal, Quebec
H4T 1H5
ird@velvetpayments.com
1-888-770-6892
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