Unique Class Member Identifier ("UCMI")
Please provide the UCMI number on the Notice you received in the mail, if you have it. The UCMI number
is above your name on the address label on the Notice you received in the mail. If you have a claim
identification number, you may skip to Part 2, below.
If you did not receive a mail notice or do not have a UCMI number, leave the UCMI number blank, and one will be assigned to you.
If your name was listed on the West Virginia Water account for your residence in 2015, please skip to the next part of the question and provide your account number.
UCMI Number
No Unique Class Member Identifier ("UCMI")
If you cannot find your UCMI or do not have one assigned to you please provide us with the following information.
Before completing this section, you may already have a UCMI number assigned to your household or business.
You can find it above your name on the address label on the Notice that was sent to you or can easily look up
your UCMI.
West Virginia Water Account Information
If you do not have a Claim Identification Number, were you the listed customer on the water bills from West
Virginia American Water to your residential address in June 2015.
If yes, and you know your West Virginia American Water account number, please provide it:
If you do not know your account number, we will check our records and try to confirm your status as a listed customer. However, it may help us to find the
correct account if you provide it.
Continue
Address of Business in June 2015
Please edit this address if incorrect.
You have elected to complete this With Evidence Claim Form because your business is able to submit evidence of
Loss of Use in the form of receipts and/or business records showing additional expenses (such as for purchases of
bottled water) and losses (such as lost inventory or lost profits) that total more than $525 . You must now submit
your evidence.
Upload an electronic copy, image, or screenshot (must be .pdf, .txt, .jpg, .jpeg, .png, .tiff, .tif, .bmp, .webp, .gif file extension)
of your receipts and/or records. You may add as many files as you would like to submit.
You may include a letter of explanation with your records, explaining, for example, how
your records you are submitting show that your business lost however much you are
claiming in lost profits between June 23, 2015, and July 1, 2015, due to Loss of Use of
water (ex., business had to close, and records from comparable times show that your
business would have made so much in profits, along with a record of the closure).
You MUST sign the verification. Your claim will NOT be processed without a signed verification. By signing the
verification, you acknowledge that under the terms of the Settlement Agreement, you are releasing all claims you
have or may in the future have against the Defendant.
I confirm under penalty of perjury that the information provided above is true and correct, and that:
(a) I understand that there can be only one Business Claim Form per Business and I have not, and to the best
of my knowledge, other members of my business have not, filed separate Business Claim Forms for this
Location;
(b) I further attest and confirm that my Business suffered "Loss of Use of property" for at least a total of 24 hours
in the period between June 23, 2015, and July 1, 2015. I understand that "Loss of Use of property" means any
impairment in the ability to use property or any of the faucets or appliances therein (ex., showers, baths, sinks,
toilets, dishwashers, washing machines, refrigerator or other water dispensers and ice makers) as a result of an
interruption or interruptions in water service or decrease in water pressure between June 23, 2015, and July 1,
2015. I also understand that receipt of a boil water advisory alone does not constitute a "Loss of Use of property"
but does not preclude a Loss of Use if accompanied by one or more interruptions in service or decreases in water
pressure that lasted a total of 24 hours;
(c) I am not excluded from the Settlement Class.
(d) I am authorized to make this Claim on behalf of the Business listed above; and
Additional Information
Under the Settlement Agreement, a Settlement Class Member does not include a natural born person or a
Business excluded from the Settlement Class. The following entities and individuals are excluded from the
Settlement Class:
West Virginia American and its officers, directors, and employees, and any affiliates of West Virginia American
and their officers, directors, and employees;
Judicial officers assigned to this case and their immediate family members and associated court staff assigned
to this case, other than court reporters;
Settlement Class Counsel and attorneys who have made an appearance for the Plaintiffs or Defendant in this
case; and
Opt Outs as defined in the Settlement Agreement.
If you are uncertain whether you are excluded from the Settlement Class or have questions, you should contact
the Settlement Administrator .