I have read and am familiar with the contents of this Proof of Claim. I certify that the information I have set forth above is true, correct
and complete to the best of my knowledge. I certify that I, or the Class Member I represent, paid the total amount set forth above in
out‐of‐pocket expenditures for purchases or reimbursements of Branded or authorized generic versions of EpiPen prescriptions between August 24,
2011, and November 1, 2020, inclusive. I further certify that I, or the Class Member I represent, did not opt out of the certified Class in
this Action. Nor did I, or the Class Member I represent, purchase such Branded or authorized generic versions of EpiPen for purposes
In addition, I: (1) have not (or the represented Class Member has not) served as counsel, officer, director, agent, or employee of any
of the Defendants, or a corporate parent, subsidiary, affiliate, or other related entity thereof; (2) did not only purchase Branded
or generic EpiPens via a fixed dollar co-payment that is the same for all covered devices, whether branded or generic
(e.g., $20 for all branded and generic devices); (3) did not purchase or receive Branded or generic EpiPens only through a Medicaid
program; (4) did not purchase Branded or generic EpiPens directly from Defendants; (4) am not one of the judges in this case or a
member of their immediate families; and (5) did not only purchase a Branded or generic EpiPen before March 13, 2014.
To the extent I have been given authority to submit this Proof of Claim by a Class Member on his or her behalf, and accordingly am
submitting this Proof of Claim in the capacity of an Authorized Agent with authority to submit it by the Class Member identified on
a separate sheet of paper submitted with this form, and to the extent I have been authorized to receive on behalf of this Class Member(s)
any and all amounts that may be allocated to him or her from the Settlement Fund, I certify that such authority has been properly
vested in me and that I will fulfill all duties I may owe the Class Member. In the event amounts from the Settlement Fund are distributed
to me and a Class Member later claims that I did not have the authority to claim and/or receive such amounts on its behalf, I and/or
my employer will hold the Class, counsel for the Class, and the Settlement Administrator harmless with respect to any claims made by
the Class Member.
I hereby submit to the jurisdiction of the United States District Court for the District of Kansas for all purposes connected with
this Proof of Claim, including resolution of disputes relating to this Proof of Claim. I acknowledge that any false information or
representations contained herein may subject me to sanctions, including the possibility of criminal prosecution. I agree to supplement
this Proof of Claim by furnishing documentary backup for the information provided herein, upon request of the Settlement Administrator.