Appalachian Land Company v. EQT Production Company

Case No. 7:08-cv-139-KKC

United States District Court for the Eastern District of Kentucky

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PLEASE FILL OUT EACH SECTION OF THE FORM:
* Required Fields
CLASS MEMBER AFFIRMATION:
By submitting this Claim Form and checking the box below, I declare that I am a member of the Settlement Class and that the following statement is true
(ALL boxes must be checked to receive payment):

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Your Claim Details

Submitted Claim ID:
Confirmation Code:
You will need the above Submitted Claim ID and Confirmation Code if you would like to edit your Claim at a later time, so please print this page for your records.
CLAIM INFORMATION
Full Name
Business Name
Street Address
City
State
Zip Code
Email Address
Phone Number
Signature
Signature Date
I affirm I was a lessor on Oil and Gas Lease with EQT Production Company (formerly known as Equitable Production Company), or its predecessors in title, during the period of January 1, 1995 through July 31, 2016, and am a member of the class as defined in the class notice.
I affirm I am NOT any of the following: (1) the United States of America; (2) any Judge or Magistrate presiding over this action or a member of their families; (3) Defendant, its affiliate, predecessor-in-interest, or its respective employee, officer or director; or (4) a potential member of the class who has been paid or accepted reimbursement for withheld severance taxed during the Class Period (between January 1, 1995 and July 31, 2016).
I declare under penalty of perjury under the laws of the State in which this affirmation is executed and the United States of America that all information provided in this Claim Form is true and correct to the best of my knowledge and belief.

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