Modified Benefit Formula Questionnaire - Greenberg Cases

SETTLEMENT CLAIM REVIEW REQUEST FORM

To Request SSA To Conduct A Settlement Claim Review

In Greenberg, et al. v. Colvin, et al., No. 1:13-cv-01837-RMC

(U.S. Dist. Court for D.C.)

** IN ORDER TO BE ELIGIBLE TO RECEIVE ANY PAYMENT PROVIDED BY THE SETTLEMENT AGREEMENT IN THIS LAWSUIT, YOU MUST REQUEST A SETTLEMENT CLAIM REVIEW **

By submitting this form, you are requesting and authorizing SSA to conduct a Settlement Claim Review. As part of a Settlement Claim Review, SSA will determine whether you fall within the definition of the “Class” in this class action lawsuit; whether or not you have excluded yourself from the Class and the Settlement Agreement in this class action lawsuit; and whether and to what extent you are eligible for a payment of money from SSA under the Settlement Agreement reached in this class action lawsuit. SSA may need to ask you questions or get additional information from you as part of the Settlement Claim Review process.

Name of Class Member:____________________________________________________________________

Address:_________________________________________________________________________________

Street City State/Province Postal Code Country

Telephone:________________________________________________________________________________

Country Code (if not U.S. phone number) Area Code/Phone No. (Ext. if applicable)

Email address:____________________________________________________________________________

United States Social Security Number of Class Member: ___________ - __________ -___________

I understand that by submitting this form, I am requesting and authorizing SSA to conduct a Settlement Claim Review. I further understand that SSA may ask me questions or that I provide SSA with additional information or documentation as part of the Settlement Claim Review process.

__________ _________________________________________________

Date Signed Signature of Class Member, or Executor, Administrator

or Personal Representative of Class Member

To be effective as a request for a Settlement Claim Review, this Settlement Claim Review Request Form must be completed in full, signed and sent by regular mail, postmarked, or delivered by hand no earlier than [DATE] but no later than [DATE], to the address listed below.

SOCIAL SECURITY ADMINISTRATION

HAGENS BERMAN SOBOL SHAPIRO LLP

Attn: Greenberg Lawsuit, Request for Settlement Claim Review, [Address]

Office of International Operations

PO Box 33001

Baltimore, Maryland 21290-3001 USA.

DC01\WilsJo\682727.1