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                                                                              CLAIM FORM

Plaintiff's claim for financial compensation arising from violation(s) of permanent injunction by defendants, et al, in the case of Merrifield v. Locker.

  ________________________________________                                  ________________________________________________
                  Claimant's Name                                                                                Company Name

Claimant's email address_________@___________________ Phone No. ____________________________________

Date of submission to the CNWCOA _____________________

Describe the nature of the financial losses suffered by you or your company arising from a violation of the permanent injunction issued against the defendants.      ________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DO NOT ATTEMPT TO ESTIMATE THE AMOUNTS OF YOUR FINANICIAL LOSSES AT THIS TIME.

Check all losses that apply in your case:

____ Loss of business income
____ Emotional distress
____ Loss of reputation
____ Restitution for paid fines, citations and                                                                                                           ____Legal expenses                                                                                                                                                       ____Loss of innovation
____ Other financial losses


I can provide the following documentation to support my claim of financial loss:

----- Cease and Desist Warning Letter sent to me
----- Citation issue to me
----- False or misleading statements made by defendants
----- Witness testimony
----- Other   Please explain___________________________________


*  Complete form and send as an email attachment to alamer99@comcast.net