DEEPWATER HORIZON ECONOMIC AND PROPERTY SETTLEMENT REAL PROPERTY SALES CLAIM FORM (ORANGE FORM) *ange* After you complete and sign your Claim Fm, submit it to the Claims Administrat as directed in the Instructions Booklet that accompanies this Claim Fm. If you submit your Claim Fm by mail delivery, do not separate this cover page from the Claim Fm. If you have to take this Claim Fm apart to photocopy fax it, make sure you include this cover page as the first page when you submit it. Real Property Sales Claim Fm
DEEPWATER HORIZON ECONOMIC AND PROPERTY SETTLEMENT REAL PROPERTY SALES CLAIM FORM (ORANGE FORM) To make a Real Property Sales Claim under the Deepwater Hizon Economic and Property Damages Settlement Agreement (the Settlement ) f damages arising from the Deepwater Hizon Incident on April 20, 2010, (the Spill ), you must complete and submit this Claim Fm and all documentation required by the Settlement ( Suppting Documentation ) to the Claims Administrat on befe June 8, 2015. The Real Property Sales Claim is f individuals businesses who prove that: (1) On April 20, 2010, they owned a Residential Parcel that is in the Real Property Sales Compensation Zone; and (2) they either (a) executed a Property Sales Contract befe April 21, 2010, but the contract price was later reduced as a result of the Spill and closed during the time period April 21, 2010, to December 31, 2010, (b) executed a Property Sales Contract on after April 21, 2010, and the sale closed during the time period April 21, 2010, to December 31, 2010. When completing this Claim Fm, refer to the accompanying booklet called Instructions f Completing the Real Property Sales Claim Fm (Orange Fm), which contains detailed instructions f completing and submitting this Claim Fm, helpful definitions, and the list of the Suppting Documentation required to prove your claim. If you have access to a computer with an internet connection, it will be far easier f you to fill out and submit your Claim Fm online, rather than on this paper Claim Fm. The online claim process will guide you through only the specific questions you need to answer, and will instruct you about the specific Suppting Documentation you must submit, based on the answers you enter as you go along. Go to www.deepwaterhizonsettlements.com to submit a claim online. If you do not have access to the internet, you may visit a Claimant Assistance Center f assistance with submitting a claim in person. Section 6 of the Real Property Sales Instructions Booklet lists all the Claimant Assistance Centers. A. Claimant Infmation Provide the following infmation about the Natural Person Business that is making this Real Property Sales Claim. 1. Name of Natural Person Business: 2. Social Security Number: Individual Taxpayer Identification Number: Employer Identification Number: Last Name Full Name of Business First Name Middle Initial SSN ITIN 3. Claimant Number: If you previously filed a claim with the Gulf Coast Claims Facility ( GCCF ), you will keep that same seven-digit Claimant Number in the Deepwater Hizon Settlement Program. Check the box at the right called GCCF Claimant Number and provide that sevendigit Claimant Number. If you did not file a claim with the GCCF, you will receive a new Claimant Number when you file your initial Registration Fm with the Deepwater Hizon Settlement Program. If you have already received your new Settlement Program Claimant Number, check the box called Deepwater Hizon Settlement Program Claimant Number and provide that nine-digit Claimant Number. If you do not yet have a Claimant Number, leave this question blank. - - EIN - GCCF Claimant Number: OR Deepwater Hizon Settlement Program Claimant Number: Real Property Sales Claim Fm Page 1
B. Infmation Required f a Real Property Sales Claim If you are making a Real Property Sales claim f me than one Parcel, photocopy this Section of the Claim Fm befe completing it and attach the copy to the Claim Fm f submission. Make one copy f each additional Parcel. 1. On April 20, 2010, did you own a Residential Parcel located within the Real Property Sales Compensation Zone, as identified on the Real Property Sales Compensation Zone Map? To determine whether your Yes No Parcel is an Eligible Parcel within the Real Property Sales Compensation Zone, see Section 3 of the Real Property Sales Instructions Booklet. If you checked Yes f Question 1, continue. If you checked No f Question 1, stop filling out this Claim Fm. If you disagree with the Claims Administrat designation of your Parcel as not within the Real Property Sales Compensation Zone as having a non-residential classification, you may request a review of your Parcel s eligibility designation. To request a review of your Parcel s eligibility designation, detach and fill out the two-page Real Property Sales Parcel Eligibility Request Fm attached to the end of this Claim Fm and submit it with the required documentation to suppt your request f a review of the eligibility designation. If your Parcel is added to the Real Property Sales Compensation Zone, you will be notified to submit a Real Property Sales Claim Fm. 2. Provide the address of the Residential Parcel f which you are making this Real Property Sales Claim. Street Unit City State Zip Code Parish/County 3. Provide the tax assessment identification number f the Parcel: 4. Provide the Parcel identification number: 5. Was the Residential Parcel involved in a feclosure proceeding Yes No between April 20, 2010, and December 31, 2010? If you checked Yes f Question 5, you are not eligible to make a Real Property Sales Claim f this Parcel and you should not complete this Claim Fm submit Suppting Documentation f a Real Property Sales Claim. If you checked No, continue. 6. Did you execute a Property Sales Contract to sell the Residential Parcel? 7. Did you close on the sale of the Residential Parcel between April 21, 2010, and December 31, 2010? If you checked Yes f both Question 6 and 7, continue. Yes Yes No No If you checked No f either Question 6 f Question 7, you are not eligible to make f a Real Property Sales Claim f this Parcel and you should not complete this Claim Fm submit Suppting Documentation f a Real Property Sales Claim. 8. Were you the sole owner of the Residential Parcel at the time of Yes No the sale? 9. If you checked No f Question 8, provide: (a) Your percentage of ownership: % (b) The full name(s) and ownership percentage of all co-owners of the Parcel at the time of the sale: Real Property Sales Claim Fm Page 2
10. If you executed the Property Sales Contract f the Residential Parcel befe April 21, 2010, was the Yes contract sale price reduced befe closing? 11. If you checked Yes f Question 10, describe why the sale price was reduced. No C. Documentation Required f a Real Property Sales Claim In addition to this Claim Fm, you must submit certain Suppting Documentation to prove your Real Property Sales Claim. The list of required documents, and instructions f how to submit them, are in Section 4 of the Real Property Sales Instructions Booklet. If you do not submit the required Suppting Documentation, the Claims Administrat will not be able to review your claim and you will not receive payment f your claim. D. Payment 1. If You Have Your Own Attney. Unless you check the box below, the Claims Administrat will make any payments jointly to you and to your attney, which means that both you and your attney will need to endse the check befe a bank will hon it. Check here if you want the Claims Administrat to make payments in connection with this and any other claim you may file in the Deepwater Hizon Economic and Property Settlement only to your attney. This means that the Claims Administrat will send your payment to your attney, who will then pay you pursuant to the retainer agreement you have with him/her. 2. If You Do Not Have Your Own Attney. If you have not retained an attney to represent you in connection with your Spill-related claim, the Claims Administrat will make any payments to which you are entitled directly to you by check. Payment checks will be sent by First Class Mail to the address you provided in the Registration Fm to the address that the Claims Administrat confirms f you during the processing of your Claim. You have an obligation to notify the Claims Administrat if your address changes. The Claims Administrat will rept annually to federal and state taxing authities, using a Fm 1099 state fm equivalent, f certain payments made. The Claims Administrat will send you a copy of that fm, but cannot give you any tax advice regarding any payment issued to you. You should consult with your own tax advis to determine the tax impact of any payment you receive from the Claims Administrat. 3. Garnishments, Liens, and other Attachments. Legally authized garnishments, liens, similar fms of attachments relating to your claim will be honed and deducted from your payment. 4. W-9 Fm Requirement. All claimants must provide a W-9 Fm. To obtain a copy of that fm, go to www.deepwaterhizonsettlements.com, request one at a Claimant Assistance Center by calling 1-866-992-6174. Real Property Sales Claim Fm Page 3
E. Signature I certify and declare under penalty of perjury pursuant to 28 U.S.C. Section 1746 that the infmation provided in this Claim Fm is true and accurate to the best of my knowledge, and that suppting documents attached to submitted in connection with this fm and the infmation contained therein are true, accurate, and complete to the best of my knowledge, and I understand that false statements claims made in connection with this Claim Fm may result in fines, imprisonment, and/ any other remedy available by law to the Federal Government, and that suspicious claims will be fwarded to federal, state, and local law enfcement agencies f possible investigation and prosecution. By submitting this Claim Fm, I consent to the use and disclosure by the Claims Administrat and those assisting the Claims Administrat of any infmation about me that they believe necessary and/ helpful to process my claim f compensation and any payment resulting from that claim. Signature: Date: / / (Month/Day/Year) First Middle Last Printed Name: Title, if a business: The claimant must sign this Claim Fm personally. No one can sign on behalf of the claimant unless the claimant is a business is deceased, a Min, Incompetent. If the claimant is a business, an authized business representative may sign. If the claimant is deceased, a Min, Incompetent, an authized Representative may sign. Real Property Sales Claim Fm Page 4
THE DEEPWATER HORIZON ECONOMIC AND PROPERTY DAMAGES SETTLEMENT REAL PROPERTY SALES PARCEL ELIGIBILITY REQUEST FORM If you disagree with the Claims Administrat designation of your Parcel as not within the Real Property Sales Compensation Zone as having a non-residential classification, detach and submit this Eligibility Request Fm instead of the Claim Fm. Refer to Section 5 of the Real Property Sales Instructions Booklet f detailed instructions about how to complete and submit this Eligibility Request Fm. DO NOT COMPLETE THIS ELIGIBILITY REQUEST FORM IF YOU ARE NOT REQUESTING A REVIEW OF THE DESIGNATION OF YOUR PARCEL OUTSIDE THE REAL PROPERTY SALES COMPENSATION ZONE. A. Reason f Requesting a Review of the Parcel s Designation Check the box next to the reason you are requesting a review of the Real Property Compensation Zone Map s designation. My Parcel is within the Real Property Sales Compensation Zone but is not identified on the Real Property Sales Compensation Zone map; My Parcel is a Residential Parcel but is not listed as Residential on the Real Property Sales Compensation Zone Map. B. Claimant Infmation Last Name Full Name of Business First Name Middle Initial 1. Name of Natural Person Business: 2. Social Security Number: SSN ITIN - - Individual Taxpayer Identification Number: EIN Employer Identification Number: - 3. Claimant Number: If you previously filed a claim with the Gulf Coast Claims Facility ( GCCF ), you will keep that same seven-digit Claimant Number in the Deepwater Hizon Settlement Program. Check the box at GCCF Claimant Number: the right called GCCF Claimant Number and provide that seven-digit Claimant Number. If you did not file a claim with the GCCF, you will receive a new Claimant Number when you file your initial Registration Fm with the Deepwater Hizon Settlement Program. If you have already received your new Settlement Program Claimant Number, check the box called Deepwater Hizon Settlement Program Claimant Number and provide that ninedigit Claimant Number. If you do not yet have a Claimant Number, leave this question blank. C. Parcel Infmation OR Deepwater Hizon Settlement Program Claimant Number: 1. Provide the address of the Parcel: Street Unit City State Zip Code Parish/County 2. Provide the tax assessment identification number f the Parcel: 3. Provide the Parcel identification number: D. Documentation Required f a Parcel Eligibility Review You must submit certain documentation to suppt your request f a review of your Parcel s designation as an ineligible Parcel. Refer to Section 5 of the Real Property Sales Instructions Booklet f a description of the Suppting Documentation you must submit along with this Eligibility Request Fm. Real Property Sales Parcel Eligibility Request Fm Page 1
E. Signature I certify and declare under penalty of perjury pursuant to 28 U.S.C. Section 1746 that the infmation provided in this Eligibility Request Fm is true and accurate to the best of my knowledge, and that suppting documents attached to submitted in connection with this fm and the infmation contained therein are true, accurate, and complete to the best of my knowledge, and I understand that false statements claims made in connection with this Eligibility Request Fm may result in fines, imprisonment, and/ any other remedy available by law to the Federal Government, and that suspicious claims will be fwarded to federal, state, and local law enfcement agencies f possible investigation and prosecution. By submitting this Eligibility Request Fm, I consent to the use and disclosure by the Claims Administrat and those assisting the Claims Administrat of any infmation about me that they believe necessary and/ helpful to process my claim f compensation and any payment resulting from that claim. Signature: Date: / / (Month/Day/Year) First Middle Last Printed Name: Title, if a business: The claimant must sign this Eligibility Request Fm personally. No one can sign on behalf of the claimant unless the claimant is a business is deceased, a Min, Incompetent. If the claimant is a business, an authized business representative may sign. If the claimant is deceased, a Min, Incompetent, an authized Representative may sign. If you are not requesting a review of the Real Property Sales Compensation Zone Map s designation of your Parcel, do NOT sign this page. If you checked Yes f Question B.1 in the Real Property Sales Claim Fm and are submitting a Real Property Sales Claim, make sure to complete and sign the Signature section on page 4 of the Claim Fm. If you sign here instead, the Claims Administrat will treat your signature as binding f the claim you file. Real Property Sales Parcel Eligibility Request Fm Page 2