GBP Sterling Libor 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

Is the Beneficial Owner an Individual?

Is the Beneficial Owner an Entity?

Representative or Custodian Name (if different from Claimant[s] listed above):

Address 1: *

Address 2:

Country: *

City: *

State/Territory: *

Zip: *

Telephone Number (home or cell): *

Telephone Number (work):

Email Address (If you provide an email address, you authorize the Claims Administrator to use it in providing you with information relevant to this claim.):

* Denotes required field

Section B – Authorized Representative Information

Name of the person you would like the Claims Administrator to contact regarding this Claim (if different from the Claimant name listed above):

Telephone Number (home or cell):

Telephone Number (work):

Address 1:

Address 2:

Country:

City:

State/Territory:

Zip:

Email Address (If you provide an email address, you authorize the Claims Administrator to use it in providing you with information relevant to this claim.):

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.

Broker Nominee Name:

Must click Add to save your information.

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.

Account Name:

Account Number:

Must click Add to save your information.

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.

Transaction Type: *

Trade Date: *

Applicable Rate (Tenor) In Months 1-12: *

Duration (Tenor): *

Notional Value (in GBP): *

Frequency Of Reset Dates In Months 1-12: *

Exit Date:

Location Of Transaction:

Counterparty Name:

Broker Name:

Confirm Proof Enclosed:

Must click Add to save your information.

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:

Swap Transaction Type: *

Swap Trade Date: *

Date of Interest Payment: *

Amount of Interest Payment (In GBP):

Notional Value (in GBP): *

Reference Interest Rate (Tenor) In Months 1-12: *

Duration (Tenor): *

Location Of Transaction:

Counterparty Name:

Broker Name:

Confirm Proof Enclosed:

Must click Add to save your information.

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:

Transaction Type: *

Trade Date: *

Notional Value (in GBP): *

Date Position Opened: *

Date Position Closed: *

Day-Count Convention:

Location Of Transaction:

Counterparty Name:

Broker Name:

Confirm Proof Enclosed:

Must click Add to save your information.

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:

Transaction Type: *

Futures Identifier: *

Open Long or Short Position: *

Number of Contracts Traded: *

Expiry Month: *

Expiry Year: *

Confirm Proof Enclosed:

Must click Add to save your information.

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:

Transaction Type: *

Contract Futures Identifier: *

Exchange: *

Trade Date: *

Contract Month: *

Contract Year: *

Number of Contracts Traded: *

Transaction Price: *

Purchase or Sale Transaction Type: *

Broker Name:

Broker Account Number:

Confirm Proof Enclosed:

Must click Add to save your information.

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:

Transaction Type: *

Futures Identifier: *

Contract Month: *

Contract Year: *

Number of Contracts Traded: *

Confirm Proof Enclosed:

Must click Add to save your information.

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.

Transaction Type: *

Option Contract Identifier: *

Trade Date: *

Exit Date:

Applicable Rate: *

Duration Tenor: *

Notional Value: *

Interest Payment Date: *

Frequency Date: *

Amount of Interest Payment: *

Location Of Transaction:

Counterparty Name:

Broker Name:

Strike Price: *

Maturity Date: *

Option Type: *

Open/Close Transaction Type: *

Disposition:

Confirm Proof Enclosed:

Must click Add to save your information.

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:

Transaction Type: *

Option Identifier: *

Trade Date: *

Contract Month: *

Contract Year: *

Number of Options Traded: *

Notional Value: *

Transaction Price: *

Purchase/Sale Transaction Type: *

Strike Price: *

Maturity Date: *

Option Type:

Disposition:

Broker Name:

Broker Account Number:

Confirm Proof Enclosed:

Must click Add to save your information.

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.

Select files

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.

NOTE: If you have been notified by the I.R.S. that you are subject to backup withholding, please strike out the language that you are not subject to backup withholding in the certification above.

Signature of Claimant (if Beneficial Owner is an individual filing on his or her own behalf): *

Authorized Representative Completing Claim Form (if any):

Capacity of Authorized Representative (if other than an individual, [e.g., trustee, executor, administrator, custodian, or other nominee]):

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.