Residential "With Evidence" Claim Form

Instructions

Please read this entire Claim Form and the Instructions carefully before you complete the Claim Form. If you are completing it by mail, type or print legibly all information in blue or black ink. Capitalized terms are defined in the Settlement Agreement and discussed in the FAQs.

Answer all applicable questions and provide all information and documents asked for on the Claim Form. ONLY COMPLETE FORMS WILL BE PROCESSED.

Part 1. Claim Information

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.

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 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.

Part 2. Identification of Residence Address for the period between June 23, 2015, and July 1, 2015 and Current Address, if different. (All Claimants Must Complete)

Please provide your address as of June 2015 and your current address and the other requested information.

Residential Street Address where you resided for any part of the period between June 23, 2015, and July 1, 2015

Please edit this address if incorrect.

Current Mailing Address to which all future correspondence should be sent (if different from the address in Part 2)

Please edit this address if incorrect.

Part 3. Identification of Resident Completing this Form (All Claimants Must Complete)

Name of Resident Completing this Form

Please edit this information if incorrect.

Current Telephone Number

Please provide a contact number if we have questions concerning your claim form; failure to provide a telephone number will not invalidate your form, but may make it more difficult for us to contact you if we have any questions or problems.

Current Email Address (Optional)

Were you the listed customer on the water bills from West Virginia American Water to your residential address in June 2015?

Part 4. Renters, Condo Owners, and other Non-Customers ONLY

You must complete this section if you were not the listed customer for the water bill for your address in June 2015. For example, if you were renting an apartment and the building owner/landlord paid the water bill for the entire building, then you are not a customer, and you must complete this section. Also, if someone you were living with in the household received the water bill directly from West Virginia American, but is unable or unwilling to submit a claim, then you may submit the claim for your household, but you must complete Part 4.

Examples of the types of documents that you may submit include:

  • A utility bill addressed to you at the Eligible Residential Location (the residence identified in Part 2);
  • A deed, lease, or rental agreement for the Eligible Residential Location showing your status as a homeowner, resident, or tenant at that location for the period between June 23, 2015, and July 1, 2015;
  • A cancelled check or check image from June 2015 showing your address and rent paid for the Eligible Residential Location; or
  • A school record, employment record, mortgage statement, or bank statement covering any part of June or July 2015 with your name and the June 2015 address you provided in Part 2;

Please provide copies of these documents. Do not send the originals.

Upload your verifiable proof of residence.

If you are completing this form by mail, please include a copy of your verifiable proof of residence in the envelope with this form.

Part 5. Selection and Submission of Evidence

You have elected to complete this With Evidence Claim Form because you are able to submit evidence of loss of use of water or monetary households losses in the form of either a message or receipt(s) from the period of the Dunbar Main Break. You must now select and submit the evidence you will submit.

Note: You may only submit one or the other form of evidence. In other words, you may submit a message or receipt(s). You may not submit both. For additional instructions, please read the FAQs. If you clicked on this form in error and you do not have either form of evidence to submit, then you should submit a Simple Claim Form under the Simple Claim Option.

You should only check this box if you have a email, text, or social media message from the period between June 23, 2015, and July 1, 2015, referring to the loss of use of water or decrease in water pressure at the Household you lived in between June 23, 2015, and July 1, 2015.

OR

You should only check this box if you have evidence in the form of receipts from the period between June 23, 2015, and July 1, 2015, for purchases of bottled water, meals at restaurants, ready-to-eat meals that do not require water for cooking, use of commercial laundry facilities, or hotels or other lodging that total more than $175.

Upload an electronic copy, image, or screenshot (must be .pdf, .txt, .jpg, .jpeg, .png, .tiff, .tif, .bmp, .webp, .gif file extension) of your message or receipts.

If you are completing this form by mail, then include a printout of the electronic copy, image, or screenshot of your message or receipts in the envelope with this form.

Part 6. Verification (All Claimants Must Complete)

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 Residential Claim Form per Household, and I have not, and to the best of my knowledge, other members of my household have not, filed separate Residential Claim Forms for this Location;

(b) I further attest and confirm that my Residence 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; and

(c) I am not excluded from the Settlement Class.

If you are a legal representative completing this form on behalf of an incapacitated or deceased Claimant, you must complete the following:

Upload or attach documentation that you have been duly appointed as legal representative for the Claimant on whose behalf you are submitting this claim form and are authorized to submit this Claim Form on Claimant's behalf.

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:

  1. West Virginia American and its officers, directors, and employees, and any affiliates of West Virginia American and their officers, directors, and employees;
  2. Judicial officers assigned to this case and their immediate family members and associated court staff assigned to this case, other than court reporters;
  3. Settlement Class Counsel and attorneys who have made an appearance for the Plaintiffs or Defendant in this case; and
  4. 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.

This form does not need to be mailed in if submitted online using the button above.