CLAIMANT CONTACT INFORMATION

Primary Address (Required)

City (Required)

Email address (Required to be compensated by e-transfer)

Telephone Number (Required)

If you are eligible for an indemnity, how do you wish to receive compensation? (Required)
Interac e-Transfer (by email)
Cheque (by mail)

1. MORTGAGE LOAN INFORMATION

1.1 Who provided your mortgage loan? (Required)
Select an option CIBC Firstline Mortgages President’s Choice Financial Other

1.2 Mortgage Start Date or most recently renewed (Required)
Month January February March April May June July August September October November December Year 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000
Do not leave blank. If the exact date is unknown, input approximate date.

1.3 What was your mortgage loan number (if available)? (Optional)

1.4 Was your mortgage for a fixed-term of 5 years or less at a fixed rate of interest? (Required)
Yes
No

1.5 Did you pay a prepayment charge? (Required)
Yes
No

1.6 What was the amount of your prepayment charge? (Required) Do not leave blank. If the exact amount is unknown, input approximate amount of your prepayment charge.

1.7 What was the interest rate applicable to your mortgage? (Required) Do not leave blank. If the exact rate is unknown, input approximate rate.

1.8 Date the mortgage loan was prepaid (Required)
Month January February March April May June July August September October November December Year 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000
Do not leave blank. If the exact date is unknown, input approximate date.

2. SPECIAL CIRCUMSTANCES (if applicable)

Have you prepaid your mortgage due to Special Circumstances as defined in the Settlement, namely due to (check off the appropriate box, if any)? (Optional)
2.1 The death of a co-borrower, as documented by a certificate of death;

2.2 The divorce of the borrower from a co-borrower, as documented by a certificate of divorce; and/or

2.3 An incapacitating illness limiting the earning capacity of the borrower or co-borrower, as documented by a medical certificate or a certificate issued by an employer, an insurer or a governmental organization.

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)

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

Date:

Full name (in lieu of signature): (Required)

Submit Claim

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