Note: You are not obliged to complete this form to participate in the class action. If you choose to do so, you are not retaining Charney Lawyers PC to act on your behalf. The information collected about potential class members on this system will assist counsel in prosecuting the class action and assessing what damages were suffered by the class as a whole. All information submitted will be treated as confidential, and will only be released as required by law or as you may consent. Providing the information requested does not make you a client of Charney Lawyers PC.