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EXHIBIT C Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29

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Page 1: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

EXHIBIT C

Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29

Page 2: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 2 of 29

Page 3: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 3 of 29

Page 4: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

Claiman

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 4 of 29

Page 5: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

Claiman

tInformation

Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 5 of 29

Page 6: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 6 of 29

Page 7: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 7 of 29

Page 8: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 8 of 29

Page 9: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 9 of 29

Page 10: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 10 of 29

Page 11: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 11 of 29

Page 12: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

Affiliate

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 12 of 29

Page 13: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 13 of 29

Page 14: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 14 of 29

Page 15: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 15 of 29

Page 16: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 16 of 29

Page 17: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 17 of 29

Page 18: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 18 of 29

Page 19: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 19 of 29

Page 20: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 20 of 29

Page 21: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

Claim

Summary

Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 21 of 29

Page 22: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 22 of 29

Page 23: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 23 of 29

Page 24: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 24 of 29

Page 25: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

Consen

ttoJurisdiction

Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 25 of 29

Page 26: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 26 of 29

Page 27: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

Claiman

tSigna

ture

Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 27 of 29

Page 28: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 28 of 29

Page 29: Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 1 of 29zeekrewardsreceivership.com/pdf/Ex. C - Claim Submission... · 2013-04-10 · Claim Portal ID Login Registration ID

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Case 3:12-cv-00519-GCM Document 138-3 Filed 03/29/13 Page 29 of 29