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Concerned Citizen Inquiry

If you believe you were affected by the data breach, please complete the form below. The information provided will only be used for communications regarding this form

First Name *

Last Name *

Address 1 *

Address 2

City *

State *

Zip Code *

Phone *

Email *

Employer *

Job Title *

Please provide a brief description of why you believe you were affected by the data breach.*

Please choose from the following options to help us better identify the harm that was caused by the data breach. (Please select at least one (1) option.)*

Unreimbursed fraud losses or charges.

Professional fees incurred in connection with identity theft or falsified tax returns.

Credit freeze.

Credit Monitoring ordered.

Lost interest or other damages resulting from a delayed state and/or federal tax refund in connection with fraudulent tax return filing.

Fraudulent bank or credit card charges.

Fraudulent tax filings.

Opening of bank accounts and/or credit cards in your name.

Government benefits taken in your name.

Miscellaneous expenses such as notary, fax, postage, gas, copying, mileage, and long-distance telephone charges.

Signature *

Date *

Please Note: Submission of this form does not mean you are represented by MEYER WILSON CO, LPA, COOPER ELLIOTT, ARNOLD & CLIFFORD, LLP or SCHIFF & ASSOCIATES CO, LPA in any way. This is solely for informational purposes only.

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Disclaimer: Schiff & Associates, Arnold & Clifford, Meyer Wilson, and Cooper & Elliott provides legal representation and legal advice to clients throughout the United States of America. Prior case results and client testimonials do not guarantee or predict a similar outcome in any future case. The photos, links, or imagery on this website are purely for dramatization purposes and do not reflect actual events of past or current clients. Please be advised that contacting the above-mentioned law firms through this website, by submitting a case description or in any manner, does not create an attorney-client relationship. An attorney-client relationship is only created through the mutual agreement of the firms and a client, as set forth in a written contingency fee agreement. Any information you provide directly through chat, email, contact form, text message, or phone call will be kept confidential. Please feel free to contact us at zschiff@schifflegal.com for any further questions.