Election Form

INSTRUCTIONS: FILL OUT AND RETURN ELECTION FORM by October 12, 2024

Please complete this form by October 12, 2024 if you wish to: (i) receive your share of the Settlement by Venmo or PayPal, or (ii) update your mailing address to receive a check by first class mail.

You are not required to complete this form in order to receive a payment.If you do not complete this form by October 12, 2024, you will receive your share of the Settlement Fund in the form of a check sent to your last known mailing address.If you would like to update your mailing address, please click here.

"*" indicates required fields

Unique Code*

4-Digit PIN*

If you received a Notice indicating that you are part of the Settlement Class, you will have a 10-character alphanumeric "Unique ID" and a 4-digit "PIN". This will be found on the top of the Notice regardless if you received it via mail or email. 

If you did not receive a Notice or have lost your Notice, please contact the Settlement Administrator by calling (877) 916-4174 (Toll-Free).

The unique code and/or PIN you entered does not match our records.

First Name*

Last Name*

Last 4 of SSN*

Email*

Phone*

Select one option below:*

OPTION ONE: RECEIVE CASH PAYMENT BY CHECK

OPTION TWO: RECEIVE ELECTRONIC PAYMENT

Electronic Payment Method*

PayPal

Venmo

I would like to receive my Settlement Benefit by paper check via First Class Mail at the following address:*

Mailing Address APT or STE # City State / Province / Region ZIP Country

I would like to receive my Settlement Benefit via PayPal.

PayPal Account

I would like to receive my Settlement Benefit via Venmo.

Venmo Account Username

Electronic Signature*

Today's Date*

Name

This field is for validation purposes and should be left unchanged.

ELECTION FORM

INSTRUCTIONS: FILL OUT AND RETURN ELECTION FORM by October 12, 2024

Deadlines:

Updates:

Gur-Ravantab, et al. v. Georgetown University Settlement Claims Administrator Contact Information: