Baer Furniture Claim Form Step 1 of 7 14% Unique ID Your claim must be submitted online or postmarked by: DECEMBER 16, 2024 Gregory Pull and Paul Greene v. Baer’s Furniture CO., Inc. Case No. 2024-CA-003418-0 Circuit Court of the 9th Judical District for Orange County, Florida Claim Form QR GENERAL INSTRUCTIONSComplete this Claim Form if you are a Settlement Class Member and you wish to receive Settlement benefits. You are a member of the Settlement Class and eligible to submit a Claim Form if: You are an individual who resides in the United States whose personal information was impacted by the Security Incident that affected Baer’s in or around August 2022. Excluded from the Settlement Class are (i) Baer’s, its officers and directors; (ii) all Settlement Class Members who timely and validly request exclusion from the Settlement Class; (iii) any judges assigned to this case and their staff and family; and (iv) any other person found by a court of competent jurisdiction to be guilty under criminal law of initiating, causing, aiding or abetting the criminal activity occurrence of the Security Incident or who pleads nolo contendere to any such charge. Settlement Class Members may submit a claim form for: (1) 2 years of credit monitoring; (2) Unreimbursed Loss Claims – up to a total of $5,000 per claimant; (3) Lost Time – $25 per hour for up to 4 hours (for a total of $100, subject to the $5,000 cap on Unreimbursed Loss Claims); (4) Alternative Cash Payment of $50 in the alternative to making a claim for Credit Monitoring, Unreimbursed Losses, and Lost Time. Credit Monitoring Services. All Settlement Class Members shall have the ability to make a claim for 2 years of credit monitoring services and identity theft protection by choosing this benefit on this Claim Form. Unreimbursed Loss claims up to $5,000 must be supported with documentation and includes any loss that is, (i) an actual, documented and unreimbursed monetary loss; (ii) that was more likely than not caused by the Security Incident; and (iii) was incurred after August 1, 2022 and before the end of the claim period, December 16, 2024. Unreimbursed losses may include losses relating to fraud or identity theft; professional fees including attorneys’ fees, accountants’ fees, and fees for credit repair services; costs associated with freezing or unfreezing credit with any credit reporting agency; credit monitoring costs that were incurred on or after mailing of the notice of data breach, through the date of claim submission; and miscellaneous expenses such as notary, fax, postage, copying, mileage, and long-distance telephone charges. Lost Time Claims must be supported by an attestation that the activities they performed were related to the Security Incident. Claims for Lost Time are subject to the $5,000 cap for Unreimbursed Losses. Alternative Cash Payment Claims In the alternative to claims for Unreimbursed Losses, Lost Time, and Credit Monitoring Services, Settlement Class Members can make a claim for a $50 Alternative Cash Payment. I. SETTLEMENT CLASS MEMBER NAME AND CONTACT INFORMATIONProvide your name and contact information below. You must notify the Settlement Administrator if your contact information changes after you submit this Claim Form. Notice ID Number* Name* First Last Address* Street Address 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 Email Address* Telephone Number* II. UNREIMBURSED LOSSES AND LOST TIME SELECTIONUnreimbursed checkbox Check this box if you are requesting compensation for Unreimbursed Losses up to a total of $5,000. *You must submit supporting documentation demonstrating actual, unreimbursed monetary loss. Complete the chart below describing the supporting documentation you are submitting. unreimbursed losses ListDescription of Documentation ProvidedAmount Supporting Documents for Unreimbursed Losses 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: 10. *You must submit supporting documentation demonstrating actual, unreimbursed monetary lossTime monitoring checkbox Check this box if you spent time monitoring accounts or otherwise dealing with issues related to the Security Incident. You can submit a claim for reimbursement of $25 per hour up to 4 hours (for a total of $100, subject to the $5,000 cap for Unreimbursed Losses). By checking this box, you are attesting that the activities you performed were related to the Security Incident. Indicate the number of hours spent**** Select Hours Spent ***1 Hour2 Hours3 Hours4 Hours III. CREDIT MONITORINGcredit monitoring checkbox Check this box if you wish to enroll in credit monitoring services for 2 years, which includes credit monitoring through Experian and $1,000,000 in identity theft insurance. IV. ALTERNATIVE CASH PAYMENTalternate payment checkbox Check this box if you wish to receive an Alternative Cash Payment of $50. You cannot receive this payment if you make a claim for Unreimbursed Losses, Lost Time, or Credit Monitoring. Claim Benefits SummaryBelow is a summary of the claims you have elected on this Claim Form. Please verify before proceeding. If you did not elect any claim benefits, please go back and select your claim benefit before proceeding.* Unreimbursed losses* Unreimbursed lost time * Credit Monitoring * Alternative Cash PaymentNo claims selected* You have not selected any claim benefits. Please go back and select at least one claim benefit to proceed. V. PAYMENT SELECTIONPlease select one of the following payment options, which will be used should you be eligible to receive a Settlement payment: Chosen Payment Method* YOU WILL RECEIVE A VERIFICATION EMAIL REGARDING YOUR DIGITAL PAYMENT. YOU MUST VERIFY AND AUTHENTICATE YOUR PAYMENT INFORMATION IN ORDER TO RECEIVE A DIGITAL PAYMENT. IF YOU DO NOT VERIFY AND AUTHENTICATE YOUR INFORMATION, A PAPER CHECK WILL BE SENT TO YOU. HiddenPayment Token* VI. ATTESTATION & SIGNATURESignature* I swear and affirm that the information provided in this Claim Form, and any supporting documentation provided is true and correct to the best of my knowledge. I understand that my claim is subject to verification and that I may be asked to provide supplemental information by the Settlement Administrator before my claim is considered complete and valid.