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

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

The deadline for submitting this proof of claim form is

Only one Settlement Claim may be submitted per Settlement Class Member.

Deficiency Reasons

Section 1. Contact Information

* Required Fields

Section 2.
Section 2. Payment Eligibility Information And Identity-Theft Protection (Required)

For more information about this Section of the Claim Form and the types of awards available and rules for receiving an award, please review the Notice and Sections 2.1 through 2.4 of the Settlement Agreement availabe on the Important Documents page.

A. Settlement Class Members may receive either a: (1) $185.00 Basic Award (subject to proration); or (2) 36 months of Identity-Theft Protection services. Which award are you claiming? (Check only one):


Settlement Class Members may receive 36 months of free identity-theft protection, called “Financial Shield” by Pango (a.k.a. Aura), instead of the Basic Award. If you opted to receive the one year of credit monitoring initially offered by Defendants, “Financial Shield” shall be in addition to that year. If you are claiming the identity-theft protection, check this box:

B. Additionally, all Settlement Class Members who incurred Out-of-Pocket expenses fairly traceable to the Security Incident may claim a Reimbursement Award:

C. All Settlement Class Members who spent time remedying issues related to the Security Incident may also claim a Time Spent Award up to five (5) hours of time at $20.00 per hour. Settlement Class Members making such a claim must attest on the Claim Form how much time they spent (up to 5 hours), in half hour increments, and that the time was actually spent remedying issues relating to the Security Incident:

D. California Subclass Members may also receive a $175.00 California Subclass Award. If you are a Settlement Class Member, you resided in California on June 11, 2021, and are claiming this award, check this box:

Section 3. Additional Information Required Only From Settlement Class Members Seeking A Reimbursement Award.

You must complete this Section if you are seeking a Reimbursement Award. Please provide as much information as possible.


Examples: Fraudulent charges that were made on your credit or debit card account and that were not reversed or repaid even though you reported them to your bank or credit card company.

Required: Attach a copy of statements that show the fraudulent charges and any correspondence showing that you reported them as unauthorized. (Please redact all unrelated transactions). If you do not have any written correspondence reporting the charges, describe when and how you reported them and to whom you reported them (attached pages as necessary):

If you are seeking reimbursement for Out-of-Pocket Expenses as part of your claim for a Reimbursement Award, complete Section 4. Otherwise, go to Section 6.

Section 4. Additional Information Required Only From Settlement Class Members Seeking Reimbursement For Out-Of-Pocket Expenses In Connection With A Reimbursement Award.

Check all that apply, stating the total amount you are claiming for each category and attaching documentation of the charges as described below. Round total amounts to the nearest dollar.


Examples: Unreimbursed card reissuance fees, unreimbursed overdraft fees, unreimbursed charges related to unavailability of funds, unreimbursed late fees, unreimbursed over-limit fees and unreimbursed fees relating to an account being frozen or otherwise unavailable due to the Security Incident.

Required: A copy of a bank or credit card statement or other proof of claimed fees or charges (please redact unrelated transactions).


Examples: Long distance or cell phone charges (if charged by the minute), or data charges (if charged based on the amount of data used).

Required: A copy of the bill from your telephone company, cell phone company, or internet service provider showing the claimed charges.


Examples: The cost of purchasing a credit report or placing a credit freeze.

Required: A copy of a receipt of other proof of purchase for each credit report, credit freeze, or credit monitoring or identity theft protection services (up to two years of coverage) purchased or placed.


Examples: Postage for correspondence with your bank or credit card company about unauthorized charges. The cost of submitting this form is not included.

Required: A copy of any receipt or proof of purchase for all postage costs claimed showing date, amount and vendor.

Section 5. Additional Information Required From Settlement Class Members Seeking A Time Spent Award.

You must complete this Section if you are seeking a Time Spent Award.

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 6. Payment Method

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

    Section 7. Fill Out and Sign the Following Attestation

    The information I have supplied in this Claim Form is true and correct to the best of my recollection and this form was executed on the date set forth below.

    I understand that all information provided on this Claim Form is subject to verification and that I may be asked to provide supplemental information by the Claims Administrator before my claim will be considered complete and valid.

    Your Claim Form has been submitted 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.
    First Name
    Last Name
    Street Address
    Street Address 2
    Zip Code
    Email Address
    Phone Number

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

    Click here to edit your Claim.