I/We have read and am/are familiar with the contents of the Instructions accompanying this Proof of Claim. I/We certify that the
information I/we have set forth in the above Proof of Claim and in any documents attached by me/us are true, correct, and complete to
the best of my/our knowledge. I/We certify that I/we, or the Class Member(s) I/we represent:
a) paid or reimbursed for brand and/or generic Diovan and Valcyte, and generic Nexium in the total amount set forth above for use
by members, employees, insureds, participants, or beneficiaries, where such persons purchased the drug in a pharmacy or received the
drug by mail-order prescription, in the United States and its territories in the applicable time periods;
b) did not seek to be excluded (“opt out”) from one or more of the Classes in this Action;
c) did not pay for or provide reimbursement of brand and/or generic Diovan and Valcyte, and generic Nexium for purposes of resale;
d) has/have not served as officer, director, management, employee of the Defendants, or their subsidiaries or affiliates; and
e) is/are not a federal and state governmental entities (except that cities, towns, municipalities or counties with self-funded
prescription drug plans may submit Proofs of Claims).
I/We further certify I/we have provided all of the information requested above to the extent I/we have it.
To the extent I/we have been given authority to submit this Proof of Claim by one or more Class Members on their behalf, and accordingly
am/are submitting this Proof of Claim in the capacity of an authorized agent with authority to submit it, and to the extent I/we have
been authorized to receive on behalf of the Class Member(s) any and all amounts that may be allocated to them from the Settlement Fund,
I/we certify that such authority has been properly vested in me and that I/we will fulfill all duties I/we may owe the Class Member(s).
If amounts from the Net Settlement Fund are distributed to me/us and a Class Member later claims that I/we did not have the authority to
claim and/or receive such amounts on its behalf, I/we and/or my/our employer will hold the Class, Lead Class Counsel, and the Settlement
Administrator harmless with respect to any claims made by the Class Member.
I/We hereby submit to the jurisdiction of the United States District Court for the District of Massachusetts for all purposes connected
with this Proof of Claim, including resolution of disputes relating to this Proof of Claim. I/We acknowledge that any false information
or representations contained herein may subject me to sanctions, including the possibility of criminal prosecution. I/We agree to
supplement this Proof of Claim by furnishing documentary backup for the information provided herein, upon request of the Settlement
I certify that the above information supplied by the undersigned is true and correct to the best of my
1. Please complete and sign the above Claim Form. Attach or upload any documentation supporting your claim.
2. Keep a copy of your Claim Form and supporting documentation for your records.
3. If you move and/or your name changes, please send your new address and/or your new name or contact information to the Settlement
Administrator at info@RanbaxyTPPLitigation.com
or via U.S. Mail at the address listed above.