Proof of Claim Form

DO NOT SUBMIT A PROOF OF CLAIM UNLESS YOU ARE NO LONGER A WATER AND SEWER CUSTOMER AS OF SEPTEMBER 30, 2022.

Only Class Members who are no longer water and sewer customers of the City of Detroit as of September 30, 2022 and do not have any unpaid account balances with DWSD that equal or exceed their Pro Rata Shares are eligible to receive a distribution of cash via check from the Net Settlement Fund.

If you are currently a water and sewer customer of the City, you will receive your Pro Rata Share in the form of a credit on your Proof of Claim forms must be received by September 30, 2022 to be eligible.

You must fill out all five sections of this Proof of Claim to be eligible for a refund.

Claim Members Name(Required)

First Last

Current Mailing Address (This is the address where we will send your refund check)(Required)

Street Address Address Line 2 City State ZIP Code

Telephone Number(Required)

Email(Required)

You must enter the service address here (This is the address of the property that received private fire line service)(Required)

Street Address Address Line 2 City State ZIP Code

List the period in which you were billed and/or paid for Private Fire Line Service in order to participate in the settlement. Please submit a separate claim form for each property for which you were billed.

Date Range From:(Required)

Through:(Required)

By submitting this claim form, I swear or affirm under penalty of perjury that I am, or am an authorized agent of, the owner of the property which was billed and/or paid the City for Private Fire Line Service at any time between July 1, 2020 and June 30, 2022, and that I am no longer a water and sewer customer of the City as of September 30, 2022.

Signature(Required)

Today's Date(Required)