1Verification of Income2Claim Form3Select Payment Option4Claim Form Acknowledge and Medical Release Form ClaimFormNoVerification of Income Form You may qualify for a settlement award if you participated in TASC’s Possession of Marijuana Deferred Prosecution Program and you were extended on the program because of your inability to pay TASC’s program fees. Please answer the following questions to the best of your ability to see if you may qualify as a member of the class who will receive an award.1.Were you on the TASC Marijuana Diversion Program between August 2016- August 2020 for more than 90 days?Q1 field(Required) Yes No Q1 Stop STOP!Unfortunately, you do not qualify as a class member THERE IS NO NEED FOR YOU TO CONTINUE WITH THIS FORM.2. Did you receive any of the following means-tested (low income) public benefits while participating in the TASC program: Welfare Arizona’s Cash Assistance Food or nutritional assistance (like SNAP or WIC) Housing assistance (like Section 8) Child care assistance, Medicaid or Arizona’s AHCCCS, or Disability benefits (like SSDI or SSRI) Q2 field Yes No 3. While participating in the TASC program, did your household earn an average approximate income of less than $24,000 per year (or $2000 per month)?Q3 field Yes No Q2OR3 ok You MAY QUALIFY as a class member. Please verify this information by filling out the rest of this claim form. Household Income Chart If you answered "No" to Question 3, follow these directions. Please select the household composition that best describes your household while you were participating in the TASC program along with your household’s average approximate income under the associated income limit. If none of the situations apply to you, please select 'Other'Household Compositions You lived in a household consisting of "Any number of people" and you believe your average approx. household income is less than $24,000/year (or $2000/month). You lived in a household consisting of "1 adult and 1 minor child" and you believe your average approx. household income is less than $46,000/year (or $3800/month). You lived in a household consisting of "1 adult and 2 minor children" and you believe your average approx. household income is less than $60,000/year (or $5000/month). You lived in a household consisting of "1 adult and 3 minor children" and you believe your average approx. household income is less than $85,000/year (or $7000/month). You lived in a household consisting of "1 adult and 4 minor children" and you believe your average approx. household income is less than $102,000/year (or $8500/month). You lived in a household consisting of "2 adults and no minor children" and you believe your average approx. household income is less than $37,000/year (or $3100/month). You lived in a household consisting of "2 adults and 1 minor child" and you believe your average approx. household income is less than $55,000/year (or $4600/month). You lived in a household consisting of "2 adults and 2 minor children" and you believe your average approx. household income is less than $69,000/year (or $5700/month). You lived in a household consisting of "2 adults and 3 minor children" and you believe your average approx. household income is less than $91,000/year (or $7700/month). You lived in a household consisting of "2 adults and 4 minor children" and you believe your average approx. household income is less than $108,000/year (or $9000/month). Other *Household is defined as a group of people who live together and share resources and expenses, such as spouses or parents and children. However, it does not include sharing housing with roommates where you do not share resources such as food. In the roommate scenario, you would be a household of 1. *Minor children are defined as children younger than 18. *Income numbers based on the Self Sufficiency Standard’s 2018 data and income levels.You indicated "Other" in the Income chart above, but you feel you may still qualify for the class because you were unable to afford TASC's program fees (based on your household composition and income during the time you were enrolled in TASC) please fill out the information below:Number of adults in your householdNumber of minor children in your householdTotal average approximate household income either yearly or monthlyAny other information about household composition or income while on TASC that you feel is relevant to determining your eligibility for the class Claimant ID(Required)Name(Required) First Last Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Social Security Number(Required)Date of Birth(Required)Phone(Required)Email(Required) TASC Settlement Payment Option - Step 2Please select the Payment Option by which you would like to receive your payment and complete the steps as prompted. Chosen Payment Method(Required)This field is hidden when viewing the formPayment Token(Required) Claim Form Declaration(Required) I declare under the penalty of perjury per 28 U.S.C. § 1746 that the foregoing information in this form is true and correct to the best of my knowledge and ability. This field is hidden when viewing the formMedical Release Authorization I I hereby authorize TASC and its attorneys to release and transfer any and all information, including private medical information and substance abuse information, ordinarily protected from disclosure under the Private Health Services Act (42 U.S.C. § 290dd- 2(a), 42.C.F.R. Part 2), or the Health Insurance Portability and Accountability Act of 1996 (Pub. L. 104-191, 110 Stat. 1936) (HIPAA), in its possession or control to Atticus Administration, the settlement administrator. I understand and authorize Atticus to disclose and share this information with attorneys for the putative class in Briggs v. TASC (D. Ariz. 2018). I further understand that this information may be used by Atticus and class counsel to assess whether I am a member of the class. This field is hidden when viewing the formMedical Release Authorization II This authorization will expire upon conclusion of the legal proceedings for which I am granting this authorization, unless otherwise specified. This field is hidden when viewing the formMedical Release Authorization III I understand that I retain the right to revoke this authorization at any time. If I revoke this authorization, I must do so in writing and present the signed and dated revocation to Atticus. I understand that the revocation will not apply to information that has already been released in response to this authorization.
