Village of Crestwood Polluted Water Litigation Claim Form

Village of Crestwood Polluted Water Litigation Claim Form

Instructions for Completing Claim Form

You may obtain and read information about the Crestwood Class Settlement, at www.villageofcrestwood.org, or by obtaining a copy of Stipulation of Settlement from the Crestwood Village Hall.

This settlement relates to the refund of certain payments made to the Village of Crestwood for water service. To be eligible for a refund of any portion of those payments, you must have resided or had a business in the Village of Crestwood during the time period January 1, 1985 through September 1, 2007 (the “Claims Period”). You also must have paid water bills to the Village of Crestwood during some portion of the Claims Period.

Please provide all requested information on the application and sign the statement on the application swearing that the information you have provided is true and correct. If you meet the conditions stated above and if you have proof of payment reflecting the amount of water bills you paid during the Claims Period, please attach copies of the proof of payment to your claim. If you do not have proof of payment for the water bills that you paid, please state how you calculated the amount of your claim.

Return the completed application, along with proof of payment if you choose, by mail to the Robert B. Boharic, Claims Administrator, P.O. Box 280, Riverside, IL 60546. Your completed application must be postmarked on or before September 30, 2010 or you will be ineligible for any refund.

If you have any questions, you may contact Class Counsel Larry D. Drury, Larry D. Drury, Ltd., 100 North LaSalle Street, Suite 1010, Chicago, IL 60602; Burton I. Weinstein, Baskin, Server, Berke & Weinstein, 20 N. Wacker Drive, Suite 1745, Chicago, IL 60606 or Ben Barnow, Barnow and Associates, P.C., One North LaSalle Street, Suite 4600, Chicago, IL 60602.

Claim form for Crestwood Class Settlement

Printed name: _________________________________
Current address: _________________________________
Current telephone numbers: home: _______________; office: _______________

A claim may be made for residential and/or business properties. For residential properties, please fill out Section A below. For business properties, please fill out Section B below. For any claim, you must also sign the verification on the following page.

A. Residences for which you paid water bills to the Village of Crestwood from January 1, 1985 through September 1, 2007.
State the Address of each of Your Residences in Crestwood, Illinois and the year(s) you resided at each address State the year(s) you paid water bills for this address Method of Calculation (if you have not attached proof of payment) Total Water Bills Paid By You For This Address from January 1, 1985 through September 1, 2007
$
$
$
$
TOTAL $
B. Business or Commercial properties for which you paid water bills to the Village of Crestwood from January 1, 1985 through September 1, 2007.
State the Name and Address of Your Business or Commercial Property in Crestwood, Illinois and the year(s) you operated the business from January 1, 1985 through September 1, 2007 State the year(s) you paid water bills for this address Method of Calculation (if you have not attached proof of payment) Total Water Bills Paid By You For This Address from January 1, 1985 through September 1, 2007
$
$
$
$
TOTAL $

I, ______________________, swear and verify under penalty of law that the
(Print your name)
Information I have provided in this application is true and correct.

__________________________________

Signature Date

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