This field is hidden when viewing the formhidden last name*This field is hidden when viewing the formhidden claimant id*Opt-Out Request Form No Opt-Out Request Form DO NOT COMPLETE OR SUBMIT THIS FORM IF YOU WANT TO BE ELIGIBLE TO RECEIVE MONEY FROM THIS SETTLEMENT, INCLUDING THE POTENTIAL FOR A CASH PAYMENT OF AT LEAST $50 Celeste Brown and Ross Finesmith v. AllCare Plus Pharmacy LLC Civil Docket No. 2484CV02366 Suffolk County Superior Court Commonwealth of Massachusetts I wish to be excluded from the proposed Settlement in the class action lawsuit entitled Celeste Brown and Ross Finesmith v. AllCare Plus Pharmacy LLC, Civil Docket No. 2484CV02366, in the Suffolk County Superior Court, Commonwealth of Massachusetts (“Lawsuit”). I understand that by excluding myself I will not be able to receive a cash benefit or credit monitoring from the proposed Settlement and I cannot object to the Settlement at the Final Approval Hearing. I do not want to be legally bound by anything that happens in this Class Action Lawsuit, and I wish to keep my right to sue the Defendant on my own for the claims that this proposed Settlement resolvesMy name, address, telephone number, and signature required to substantiate my request to be excluded from the above titled Action, are as follows:Full Name First Name Last Name Mailing 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 Current Email* Claimant ID Number*Signature* By signing below, I certify that to the best of my knowledge, the information on this Form is true and correct. Date MM slash DD slash YYYY YOUR EXCLUSION REQUEST FORM MUST BE SUBMITTED NO LATER THAN JULY 3, 2025, TO BE CONSIDERED. Unique IDNameThis field is for validation purposes and should be left unchanged.
