If you received a personalized notice in the mail or via email with a Unique ID and Confirmation Code, please enter the codes you were provided below.

Please remember to enter the full Unique ID exactly as it appears on your personalized Notice, (i.e. 12345678).

“OUT-OF-POCKET LOSS” CLAIM FORM

IN ORDER TO BE VALID, THIS CLAIM FORM MUST BE RECEIVED NO LATER THAN AUGUST 30, 2023.

ATTENTION: This Claim Form is to be used to apply for out-of-pocket losses you believe are fairly traceable to the Data Breach that affected some Dave Inc. users in summer 2020. Specifically, Dave users who were California residents at the time of the Data Breach and whose personal information was subject to the Data Breach, as confirmed by Dave Inc.’s business records. To submit a Claim, you must have been identified as a potential Settlement Class Member from Defendant Dave Inc.’s business records and received E-Mailed or mailed Notice of this Settlement with a unique Claim Number You may qualify for a payment of up to $1,500.00 for reimbursement of out-of-pocket losses, including time spent remedying identity theft or fraud, including misuse of personal information, credit monitoring or freezing credit reports at twenty-five dollars ($25.00) for up to 10 hours. You will need to submit proof of your losses to be eligible. PLEASE BE ADVISED that any documentation you provide must be submitted WITH this Claim Form.

ATTENTION: This Claim Form is to be used to apply for damages related to the Data Breach, which affected some Dave Inc. users in summer 2020. Specifically, users who were California residents at the time of the Data Breach and whose encrypted social security number and/or hashed password were exposed in the Data Breach, as confirmed by Dave’s business records. There are two types of damages for which these users may be eligible, 1) statutory damages, and 2) reimbursement of actual losses that are fairly traceable to the Data Breach, including attested time.

To submit a Claim, you must have been identified as a potential Settlement Class Member from Defendant Dave Inc.’s business records and received E-Mailed or mailed Notice of this Settlement with a unique Claim Number. If you apply for statutory damages, you may qualify for a payment of up to $75.00 (the “Statutory Claim”).

You may also apply to be reimbursed for your actual out-of-pocket losses, up to $1,500.00, which may include reimbursement for time spent remedying identity theft or fraud, including misuse of personal information, credit monitoring or freezing credit reports at twenty-five dollars ($25.00) for up to 10 hours (the “Out-of-Pocket Loss Claim”). You will need to submit proof of your losses in order to be eligible. PLEASE BE ADVISED that any documentation you provide must be submitted WITH this Claim Form.

Note that you MUST separately apply for statutory damages and out-of-pocket losses, including attested time using this Claim Form.

CLAIM VERIFICATION: All Claims are subject to verification. You will be notified if additional information is needed to verify your Claim.

ASSISTANCE: If you have questions about this Claim Form, please call 1(866) 875-6779.

PLEASE KEEP A COPY OF YOUR CLAIM FORM AND PROOF OF SUBMISSION FOR YOUR RECORDS.

Failure to submit required documentation, or to complete all parts of the Claim Form, may result in denial of the claim, delay its processing, or otherwise adversely affect the claim.

REGISTRATION

* Required Fields

CLAIM INFORMATION

Section A. Confirm Your Eligibility

Did you receive a Unique ID indicating that you may be a member of the Settlement Class?

If yes, continue to the next question. If no, you are not a member of the Settlement Class and do not qualify to file a Claim.

Did you suffer any financial expenses or other financial losses as a result of the Data Breach? For example, did you sign up and pay for a credit monitoring service, hire and pay for a professional service to remedy identity theft, etc. attributed to the Data Breach?

If yes, you may be eligible to fill out Section B of this form and provide corroborating documentation.

Section B. California Statutory Claims

Dave’s business records indicate that you may be eligible to seek payment as relief for the Statutory Claim aspect of the settlement, subject to verification of certain information.

To verify eligibility, you must provide your full name and your email address, which will be validated against the information that you previously provided to Dave and on file at the time of the Data Breach. Only Settlement Class Members whose encrypted social security number and/or hashed password were exposed in the Data Breach may submit a Statutory Claim. If it is verified that you meet all the criteria described in the Settlement Agreement and the information you provide below matches the information in Dave’s business records, you will be eligible to receive a payment of up to $75.00. The information you provide must match exactly with what you provided when you signed up for Dave. If it does not, the Settlement Administrator will deny your claim.

If the total dollar amount of Claims for losses exceeds the limits set by the Settlement Agreement, your Statutory Claim payment may be reduced, depending on the number of valid Claims received.

Payment for your Statutory Claim will be paid directly to you electronically. If you do not wish to receive an electronic payment, you can request to receive payment by check and sent to the mailing address you provided above.

Section B. Reimbursement for Documented Losses

If you suffered verifiable financial losses that are fairly traceable to the Data Breach, you may be eligible to receive a payment to compensate you for the losses and inconveniences suffered that are fairly traceable to the Data Breach.

If it is verified that you meet all the criteria described in the Settlement Agreement, and you submit proof of your losses and the dollar amount of those losses, you will be eligible to receive a payment compensating you for your documented losses of up to $1,500.00. Examples of what can be used to prove your losses include: receipts, account statements, etc. You may also prove losses by submitting information in the Claim Form that describes time spent remedying suspected identity theft, fraud, or misuse of personal information and/or other issues fairly traceable to the Data Breach. You will be required to provide an attestation and a brief description of (1) the action taken in response to the Data Breach; and (2) the time associated with each action. If you submit this information, you will be eligible for a payment of up to $25.00 per hour, for up to 10 hours. Examples of what can be used to establish your losses related to time spent remedying issues fairly traceable to the Data Breach include: time spent monitoring credit, resolving disputes for unauthorized transactions, freezing or unfreezing your credit, remedying a falsified tax return, etc.

Providing adequate proof of your losses does not guarantee that you will be entitled to receive the full amount claimed. All Claims will also be subject to an aggregate maximum payment amount, as explained in the Settlement Agreement. If the amount of losses claimed exceeds the maximum amount of money available under the Settlement Agreement, then the payment for your Claim will be reduced on a pro rata basis. If you would like to learn more, please review the Settlement Agreement for further details. All losses will also be subject to a verification process.

Payment for your losses will be paid directly to you electronically, unless you request to be paid by check as indicated below.

For each loss you believe can be traced to the Data Breach, please provide a description of the loss, the date of the loss, the dollar amount of the loss, and the type of documentation you will be submitting to support the loss. You must provide ALL this information for this Claim to be processed. Supporting documents must be submitted electronically. Please do so as part of this Claim Form and provide the additional information required below. If you fail to provide sufficient supporting documents, the Settlement Administrator will deny Your Claim. Please provide only copies of your supporting documents and keep all originals for your personal files. The Settlement Administrator will have no obligation to return any supporting documentation to you. A copy of the Settlement Administrator’s privacy policy is available here. With the exception of your Dave account number, name, and address, supporting documentation will not be provided to the Defendant in this action.

Examples of such losses include payments for identity theft protection or credit monitoring you made which are fairly traceable to the Data Breach, financial losses due to stolen identity traceable to the Data Breach, etc. These are only examples and do not represent a complete list of losses eligible for compensation. Please provide a description of any loss that you claim was the result of the Data Breach.

Examples of documentation include receipts for identity theft protection services, etc.

Description of the Loss Date of Loss Amount Type of Supporting Documentation
Example:
Payment for Identity Theft Protection Service		 07/17/2020 50.00 Copy of identity theft protection service bill
Example:
Fees paid to a professional to remedy a falsified tax return		 07/20/2020 25.00 Copy of professional services bill
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Reimbursement for Attested Time:

Settlement Class Members may submit a claim for up to 10 hours of time spent remedying identity theft, fraud, misuse of personal information, credit monitoring or freezing credit reports, and/or other issues fairly traceable to the Data Breach at $25.00 per hour by providing an attestation and a brief description of (1) the action taken in response to the Data Breach; and (2) the time associated with each action.

Date of Time Spent Amount of Time Description of the Action Taken
07/17/2020 1 Hour Example: Review my credit report
07/20/2020 1.5 Hours Example: Call with bank to dispute transaction.
Hour(s)
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Additional Information

By checking the below box, I hereby declare under penalty of perjury under the laws of the State of California that the information provided in this Claim Form to support my seeking relief for Attested Time (up to $250.00) is true and correct. I further certify that any documentation that I have submitted in support of my Claim for Attested Time consists of unaltered documents in my possession.

Section C. Supporting Documentation

Accepted file types are: PDF, TIF, JPG, GIF, PNG. Other file types will be rejected.

Please confirm in the grid below that your file has been successfully uploaded.

File List: No Files Selected

    Section D. Payment

    You have successfully requested a payment. Click here if you would like to choose a different payment method.

    Section E. Settlement Class Member Affirmation

    By submitting this Claim Form and checking the box below, I declare that I received notification from Dave that I have been identified as a potential Settlement Class Member. As I have submitted claims of losses due to the Data Breach, I declare that I suffered these losses.

    I understand that my Claim and the information provided above will be subject to verification.

    I also understand that I may not be entitled to recover under this Settlement if I am employed by and/or affiliated with the Judge or Magistrate presiding over this action, and/or am employed by the Defendant or anyone acting on its behalf.

    Your Claim Form has been updated successfully.

    Please print this page for your records.

    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
    First Name
    Last Name
    Street Address
    Street Address 2
    City
    State
    Province
    Zip Code
    Postal Code
    Country
    Email Address
    Phone Number
    Signature
    Date

    If you have any questions regarding your Claim, please provide the Submitted Claim ID listed above and email us at Info@DataBreachSettlementDaveInc.com

    Click here to edit your Claim.

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