Settlement Claim Deadline Extension Request Form
Please complete this form to request an extension of your settlement claim deadline. All fields are required to evaluate your request.
Claimant Full Name
*
First Name
Last Name
Contact Email Address
*
example@example.com
Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Claim Number or Reference ID
*
Relationship to the Claim
*
Please Select
Claimant
Attorney
Representative
Other
Original Claim Deadline
*
-
Month
-
Day
Year
Date
Requested New Deadline
*
-
Month
-
Day
Year
Date
Reason for Extension Request
*
Supporting Documentation (optional)
Upload a File
Drag and drop files here
Choose a file
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of
Additional Comments or Information
Submit Extension Request
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