Sterling Libor Securities Settlement

CLAIMANT IDENTIFICATION

The Settlement Administrator will use this information for all communications relevant to this Claim Form. If this information changes, please notify the Settlement Administrator in writing. If you are a trustee, executor, administrator, custodian, or other nominee and are completing and signing this Claim Form on behalf of the Claimant, you must attach documentation showing your authority to act on behalf of the Claimant.

Section A – Claimant Information


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Section B – Authorized Representative Information


TRANSACTIONS IN STERLING LIBOR-BASED DERIVATIVES

Provide the following information only if you entered into transactions in Sterling LIBOR-Based Derivatives from January 1, 2005, through December 31, 2010. Do not include information regarding instruments other than Sterling LIBOR-Based Derivatives and do not include transactions in Sterling LIBOR-Based Derivatives in which you acquired the instrument as an agent for another individual or entity.



List of Brokers or Nominees
Provide all brokers or nominees at which you maintained accounts in which you traded or held in Sterling LIBOR-Based Derivatives.


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Broker or Nominee Action



List of Account Names and Account Numbers
Please provide a list of all account names and account numbers for each entity you listed in response above in which you traded or held Sterling LIBOR-Based Derivatives.


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Account Name Account Number Action




FORWARD RATE AGREEMENTS (“FRAS”) AND INTEREST RATE SWAPS WITH A CONSTANT NOTIONAL VALUE PURCHASED, SOLD, HELD, OR TRADED DURING THE CLASS PERIOD


For each FRA, and/or swap with a constant notional value that was purchased, sold, held, or traded during the Class Period, provide the following information for each transaction.





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Transaction Type Trade Date Applicable Rate (Tenor) Duration (Tenor) Notional Value (in GBP) for Interest Payment Frequency of Reset Dates Exit Date Location of Transaction Counterparty Name Broker Name Confirm Proof of Purchase Enclosed Action




STERLING LIBOR-BASED INTEREST RATE SWAPS WITH A VARIABLE NOTIONAL VALUE PURCHASED, SOLD, HELD, OR TRADED DURING THE CLASS PERIOD


For each purchase or sale of a swap whose notional value fluctuated during the contract period, provide the following information for each interest payment for each transaction during the Class Period. please add additional rows to reflect all interest payments associated with the transaction. For example, if there were ten interest payments for a particular transaction, list the dates of all ten interest payments, the notional value (in GBP) on which each interest payment was calculated, and the amount of each interest payment:


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Swap Transaction Type Swap Trade Date Date of Interest Payment Amount of Interest Payment Notional Value (in GBP) for Interest Payment Reference Interest Rate (Tenor) Duration (Tenor) Location of Transaction Counterparty Name Broker Name Confirm Proof of Purchase Enclosed Action




PURCHASE(S) AND SALE(S) OF CURRENCY (“FX”) FORWARDS AND SWAPS DURING THE CLASS PERIOD


For a purchase or sale of a foreign exchange (“FX”) forward or swap, provide the following information for each transaction:



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Transaction Type Trade Date Notional Value (in SGD) Date Position Opened Date Position Closed Day-Count Convention Location of Transaction Counterparty Name Broker Name Confirm Proof of Purchase Enclosed Action




OPEN POSITIONS IN CME BRITISH POUND CURRENCY FUTURES CONTRACTS AND/OR LIFFE THREE-MONTH STERLING FUTURES CONTRACTS PRIOR TO THE START OF THE CLASS PERIOD


As of end of the day on December 31, 2004, please list your open positions in CME British pound currency futures contracts or LIFFE three-month Sterling futures contracts transacted by a Person domiciled in the United States or its territories or, if domiciled outside the United States or its territories, transacted by a Person from a location within the United States or its territories, and provide the following information for each transaction:



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Transaction Type Futures Identifier Long/Short Position Number of Contracts Expiry Month Expiry Year Confirm Proof of Purchase Enclosed Action




PURCHASE(S) AND SALE(S) OF CME BRITISH POUND CURRENCY FUTURES CONTRACTS AND/OR LIFFE THREE-MONTH STERLING FUTURES CONTRACTS DURING THE CLASS PERIOD


During the Class Period, for a purchase or sale of a CME British pound currency futures contract or a LIFFE three-month Sterling futures contract transacted by a Person domiciled in the United States or its territories or, if domiciled outside the United States or its territories, transacted by a Person from a location within the United States or its territories, provide the following information for each transaction:



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Transaction Type Contract Futures Identifier Exchange Trade Date Contract Month Contract Year Number of Contracts Transaction Price Purchase or Sale Broker Name Broker Account Number Confirm Proof of Purchase Enclosed Action




OPEN POSITIONS IN CME BRITISH POUND CURRENCY FUTURES CONTRACTS AND/OR LIFFE THREE-MONTH STERLING FUTURES CONTRACTS AT THE END OF THE CLASS PERIOD



As of end of the day on December 31, 2010, please list your open positions in CME British pound currency futures contracts or LIFFE three-month Sterling futures contracts transacted by a Person domiciled in the United States or its territories or, if domiciled outside the United States or its territories, transacted by a Person from a location within the United States or its territories, and provide the following information for each transaction:



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Transaction Type Futures Identifier Contract Month Contract Year Number of Contracts Confirm Proof of Purchase Enclosed Action



INTEREST RATE OPTIONS AND SWAPTIONS PURCHASED, SOLD, OR TRADED DURING THE CLASS PERIOD


For each interest rate option and/or swaption that was purchased, sold, held, or traded during the Class Period, provide the following information for each transaction.



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Transaction Type Option Contract Identifier Trade Date (yyyy-mm-dd) Exit Date Applicable Rate Duration Tenor Notional Value Interest Payment Date Frequency Date Amount of each interest payment Transaction Location Counterparty Name Broker Name Strike Price Maturity Date Option Type Open/Close Transaction Disposition (Assign/Exercise/Expire) Confirm Proof of Purchase Enclosed Action



PURCHASE(S) AND SALE(S) OF FX OPTIONS DURING THE CLASS PERIOD


For a purchase or sale of a FX option, provide the following information for each transaction:



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Transaction Type Futures Identifier Trade Date (yyyy-mm-dd) Contract Month Contract Year Number of Options Notional Value Transaction Price Transaction Type (Purchase/Sale) Strike Price Maturity Date Option Type Disposition Broker Name Account Number Confirm Proof of Purchase Enclosed Action

It is important that you accurately disclose all transactions in Sterling LIBOR-Based Derivatives during the Class Period. Plaintiffs’ Counsel and the Settlement Administrator reserve the right to seek further information from you regarding your Claim Form.

UPLOAD SUPPORTING DOCUMENTS


All supporting documentation for your positions and transactions should be uploaded to this page prior to moving on to the next step in your online claim submission.

Please use the browse option, by clicking on “Select Files” in the box below, to upload your supporting documentation being submitted to verify all of your positions and transactions.




Files To Be Uploaded Size Action
CLAIMANT’S CERTIFICATION & SIGNATURE

Certification

BY SIGNING AND SUBMITTING THIS CLAIM FORM, CLAIMANT OR CLAIMANT’S AUTHORIZED REPRESENTATIVE CERTIFIES ON CLAIMANT’S BEHALF AS FOLLOWS:

1. I (we) have read the Notice and Claim Form, including the descriptions of the Release and Covenant Not to Sue provided for in the Settlement Agreements;

2. I (we) am (are) a Class Member and am (are) not one of the individuals or entities excluded from the Settlement Class;

3. I (we) have not submitted a Request for Exclusion;

4. I (we) have made the transactions submitted with this Claim Form for myself (ourselves) and not as agents of another, and have not assigned my (our) Released Claims to another;

5. I (we) hereby warrant and represent that I (we) have not assigned or transferred or purported to assign or transfer, voluntarily or involuntarily, any matter released pursuant to the release or any other part or portion thereof;

6. I (we) have not submitted any other claim in this Action covering the same transactions and know of no other person having done so on his/her/its/their behalf;

7. I (we) hereby consent to the disclosure of, waive any protections provided by any applicable bank secrecy or data privacy laws (whether foreign or domestic), or any similar confidentiality protections with respect to, and instruct Settling Defendants or any authorized third party to disclose my (our) information and transaction data relating to my (our) trades for use in the claims administration process;

8. I (we) submit to the jurisdiction of the Court with respect to my (our) claim and for purposes of enforcing the releases set forth in any Final Judgment that may be entered in the Action;

9. I (we) agree to furnish such additional information with respect to this Claim Form as the Settlement Administrator or the Court may require; and

10. I (we) acknowledge that I (we) will be bound by and subject to the terms of the Judgment that will be entered in the Action if the Settlement is approved.

11. I (we) certify that I am (we are) not subject to backup withholding under the provisions of Section 3406(a)(1)(C) of the Internal Revenue Code.


Signature

Please Read The Release, Consent To Disclosure And Certification, And Sign Below.

I (we) acknowledge that, as of the Effective Date of the Settlement, pursuant to the terms set forth in the Settlement Agreement, and by operation of law and the Final Judgment, I (we) shall be deemed to release and forever discharge and shall be forever enjoined from prosecuting the Released Claims against the Released Parties (as defined in the Settlement Agreement and/or Final Judgment).

By signing and submitting this Claim Form, I (we) consent to the disclosure of information relating to my (our) transactions in BBSW-Based Derivatives during the Class Period, and waive any protections provided by any applicable bank secrecy or data privacy laws (whether foreign or domestic), or any similar confidentiality protections with respect to information and transaction data relating to my (our) trades, for use in the claims administration process.

If signing as an Authorized Representative on behalf of an entity, I (we) certify that I (we) have legal rights and authorization from the entity to file this Claim Form on the entity’s behalf. UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES OF AMERICA, I (WE) CERTIFY THAT ALL THE INFORMATION PROVIDED BY ME (US) ON THIS CLAIM FORM IS TRUE, CORRECT, AND COMPLETE AND THAT THE DATA SUBMITTED IN CONNECTION WITH THIS CLAIM FORM ARE TRUE AND CORRECT COPIES OF WHAT THEY PURPORT TO BE.




REMINDER: YOUR CLAIM FORM AND REQUIRED DATA MUST BE SUBMITTED ONLINE BY 11:59 P.M. EASTERN TIME ON JANUARY 16, 2024, OR POSTMARKED AND MAILED NO LATER THAN JANUARY 16, 2024.

GBP LIBOR Class Action Settlement
c/o A.B. Data, Ltd.
P.O. Box 173111
Milwaukee, WI 53217

Do not submit your claim to the Court.